Provider Demographics
NPI:1720756554
Name:WALSH, SARAH RENE (PA-C)
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:RENE
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 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-2500
Practice Address - Fax:317-962-2515
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-06
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
IN10003444A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INQ00404992OtherRAILROAD PTAN
IN1000125008OtherANTHEM PTAN
IN264430E36OtherMEDICARE
IN300066187Medicaid