Provider Demographics
NPI:1821304007
Name:WALSH, MELISSA A (PA-C)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:A
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:A
Other - Last Name:IRELAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:4301 GARRITY BLVD STE 103
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-9222
Mailing Address - Country:US
Mailing Address - Phone:855-434-7763
Mailing Address - Fax:949-281-5550
Practice Address - Street 1:4301 GARRITY BLVD STE 103
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83687-9222
Practice Address - Country:US
Practice Address - Phone:855-434-7763
Practice Address - Fax:949-281-5550
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-856363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1770817413Medicaid