Provider Demographics
NPI:1790224871
Name:WALSH, ALVIN III (NP-C)
Entity Type:Individual
Prefix:MR
First Name:ALVIN
Middle Name:
Last Name:WALSH
Suffix:III
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2101 HIGHWAY 90
Mailing Address - Street 2:
Mailing Address - City:GAUTIER
Mailing Address - State:MS
Mailing Address - Zip Code:39553-5340
Mailing Address - Country:US
Mailing Address - Phone:228-497-7576
Mailing Address - Fax:228-497-8869
Practice Address - Street 1:12330 ASHLEY DR
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2737
Practice Address - Country:US
Practice Address - Phone:228-832-9038
Practice Address - Fax:228-832-9990
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-22
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS901904363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06082764Medicaid
MS575390YXF9OtherMEDICARE PTAN
MS901904OtherSTATE LICENSE NUMBER