Provider Demographics
NPI:1508589599
Name:WALSH, KEDRON (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:KEDRON
Middle Name:
Last Name:WALSH
Suffix:
Gender:
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5531 SCOTSVIEW DR
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE FORGE
Mailing Address - State:VA
Mailing Address - Zip Code:23140-4470
Mailing Address - Country:US
Mailing Address - Phone:804-384-8418
Mailing Address - Fax:
Practice Address - Street 1:2200 PUMP RD STE 100
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23233-3539
Practice Address - Country:US
Practice Address - Phone:804-741-7141
Practice Address - Fax:804-741-6082
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-23
Last Update Date:2025-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110009668207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty