Provider Demographics
NPI:1962819888
Name:WALSH, MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:WALSH
Suffix:
Gender:M
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:PO BOX 414977
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-4977
Mailing Address - Country:US
Mailing Address - Phone:781-280-1500
Mailing Address - Fax:781-276-6410
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:781-280-1500
Practice Address - Fax:781-276-6410
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MAPA5072363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant