Provider Demographics
NPI:1821140799
Name:WALSH, TERRANCE L (PA)
Entity Type:Individual
Prefix:
First Name:TERRANCE
Middle Name:L
Last Name:WALSH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1273 N 72ND AVE
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-8914
Mailing Address - Country:US
Mailing Address - Phone:231-873-3087
Mailing Address - Fax:
Practice Address - Street 1:7 N ATKINSON DR
Practice Address - Street 2:SUITE 112
Practice Address - City:LUDINGTON
Practice Address - State:MI
Practice Address - Zip Code:49431-1953
Practice Address - Country:US
Practice Address - Phone:231-843-3717
Practice Address - Fax:231-845-6198
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601001538363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical