Provider Demographics
NPI:1881774008
Name:WALSH, DUSTIN A (PA)
Entity type:Individual
Prefix:MR
First Name:DUSTIN
Middle Name:A
Last Name:WALSH
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:194 WINIFRED RD
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:GA
Mailing Address - Zip Code:31763-4608
Mailing Address - Country:US
Mailing Address - Phone:229-869-5841
Mailing Address - Fax:
Practice Address - Street 1:804 13TH AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1328
Practice Address - Country:US
Practice Address - Phone:229-438-5864
Practice Address - Fax:229-438-1004
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA1473363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I973401Medicare PIN
511G701098Medicare PIN