Provider Demographics
NPI:1922398916
Name:WALSH, JESSICA (PA)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:
Other - Last Name:SCHNELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:711 TROY SCHENECTADY RD
Mailing Address - Street 2:SUITE 203
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-2442
Mailing Address - Country:US
Mailing Address - Phone:518-782-3700
Mailing Address - Fax:518-782-3799
Practice Address - Street 1:2125 RIVER RD
Practice Address - Street 2:SUITE 100
Practice Address - City:NISKAYUNA
Practice Address - State:NY
Practice Address - Zip Code:12309-1135
Practice Address - Country:US
Practice Address - Phone:518-836-3030
Practice Address - Fax:518-836-3020
Is Sole Proprietor?:No
Enumeration Date:2011-04-12
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014704363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03433043Medicaid
NYJ400248575Medicare PIN