Provider Demographics
NPI:1851934491
Name:WALSH, KAITLIN MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 FOUST ST STE C
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5476
Mailing Address - Country:US
Mailing Address - Phone:336-625-2333
Mailing Address - Fax:336-625-5511
Practice Address - Street 1:713 S FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-6667
Practice Address - Country:US
Practice Address - Phone:336-625-2467
Practice Address - Fax:336-625-2256
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024357208000000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1851934491Medicaid