Provider Demographics
NPI:1962867457
Name:WALSH, JOSEPH RYAN (PA)
Entity Type:Individual
Prefix:MR
First Name:JOSEPH
Middle Name:RYAN
Last Name:WALSH
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:636-916-7140
Mailing Address - Fax:636-916-7139
Practice Address - Street 1:100 ENTRANCE WAY
Practice Address - Street 2:DEPT NEUROLOGICAL SURGERY, STE B
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-1645
Practice Address - Country:US
Practice Address - Phone:636-916-7140
Practice Address - Fax:636-916-7139
Is Sole Proprietor?:No
Enumeration Date:2015-12-28
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO2016004094363A00000X
MO2015044455363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO220035332Medicaid