Provider Demographics
NPI:1992725667
Name:WALSH, CHARLENE M (PA-C)
Entity type:Individual
Prefix:MRS
First Name:CHARLENE
Middle Name:M
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:888 CHURCH ST N
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-4350
Mailing Address - Country:US
Mailing Address - Phone:704-786-6122
Mailing Address - Fax:704-784-9102
Practice Address - Street 1:888 CHURCH ST N
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-4350
Practice Address - Country:US
Practice Address - Phone:704-786-6122
Practice Address - Fax:704-784-9102
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC103959363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC103959OtherNC MEDICAL BOARD