Provider Demographics
NPI:1760594196
Name:WALSH, SUSAN IRENE (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:IRENE
Last Name:WALSH
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3781 METARKO RD
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:NY
Mailing Address - Zip Code:14801-9380
Mailing Address - Country:US
Mailing Address - Phone:607-359-3267
Mailing Address - Fax:
Practice Address - Street 1:76 VETERANS AVE
Practice Address - Street 2:
Practice Address - City:BATH
Practice Address - State:NY
Practice Address - Zip Code:14810-0810
Practice Address - Country:US
Practice Address - Phone:607-664-4614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF334220363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily