Provider Demographics
NPI:1215586193
Name:WALSH, PATRICIA DANIELLE (PA-C)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:DANIELLE
Last Name:WALSH
Suffix:
Gender:
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 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6213
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:1400 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:KY
Practice Address - Zip Code:41071-2570
Practice Address - Country:US
Practice Address - Phone:859-212-0497
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-04
Last Update Date:2025-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.007248363A00000X
KYPA2437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant