Provider Demographics
NPI:1760416275
Name:WALSH, NICOLETTE C (MD)
Entity Type:Individual
Prefix:DR
First Name:NICOLETTE
Middle Name:C
Last Name:WALSH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4247 W RIDGE RD STE 105
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-1746
Mailing Address - Country:US
Mailing Address - Phone:814-838-2468
Mailing Address - Fax:
Practice Address - Street 1:4247 W RIDGE RD STE 105
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16506
Practice Address - Country:US
Practice Address - Phone:814-838-2468
Practice Address - Fax:814-835-2599
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-10
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041295L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAE55003Medicare UPIN
PA607535Medicare ID - Type Unspecified