Provider Demographics
NPI:1386893089
Name:WALSH, JOHN T (PA, CDE)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:T
Last Name:WALSH
Suffix:
Gender:M
Credentials:PA, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:625 W CITRACADO PKWY SUITE 108
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025
Mailing Address - Country:US
Mailing Address - Phone:760-743-1431
Mailing Address - Fax:760-743-6455
Practice Address - Street 1:625 W CITRACADO PKWY SUITE 108
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025
Practice Address - Country:US
Practice Address - Phone:760-743-1431
Practice Address - Fax:760-743-6455
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2021-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant