Provider Demographics
NPI:1760641062
Name:WALSH, KATHLEEN (PNP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5900 N BURDICK ST
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9462
Mailing Address - Country:US
Mailing Address - Phone:315-656-8750
Mailing Address - Fax:315-656-8493
Practice Address - Street 1:5900 N BURDICK ST
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9462
Practice Address - Country:US
Practice Address - Phone:315-656-8750
Practice Address - Fax:315-656-8493
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380978363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics