MEDICARE: KRISTEN WALSH PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant
2	363A00000X	Physician Assistant	PA64517	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PA64517	OTHER	CA	PA BOARD OF CALIFORNIA

General Provider Information

NPI Number	:	1417706714
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN WALSH PA-C

Provider Business Mailing Address
First Line	:	46 HILLSDALE MALL
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-3407
Country	:	US
Telephone Number	:	650-292-0847
Fax Number	:

Provider Business Practice Location Address
First Line	:	46 HILLSDALE MALL
Second Line	:
City	:	SAN MATEO
State	:	CA
Zip	:	94403-3407
Country	:	US
Telephone Number	:	650-292-0847
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/17/2024
Last Update Date	:	04/22/2025

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