Provider Demographics
NPI:1427799634
Name:WALSH, TINA MARIE (DO)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIE
Last Name:WALSH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:MARIE
Other - Last Name:PANICHI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:20 COLE LN
Mailing Address - Street 2:
Mailing Address - City:WYNANTSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12198-7806
Mailing Address - Country:US
Mailing Address - Phone:518-779-5179
Mailing Address - Fax:
Practice Address - Street 1:1 ATWELL RD
Practice Address - Street 2:
Practice Address - City:COOPERSTOWN
Practice Address - State:NY
Practice Address - Zip Code:13326-1301
Practice Address - Country:US
Practice Address - Phone:607-574-3465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-05
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program