Healthcare Provider Details

I. General information

NPI: 1386893089
Provider Name (Legal Business Name): JOHN T. WALSH P.A., C.D.E.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2008
Last Update Date: 04/16/2021
Certification Date: 04/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 W CITRACADO PKWY SUITE 108
ESCONDIDO CA
92025
US

IV. Provider business mailing address

625 W CITRACADO PKWY SUITE 108
ESCONDIDO CA
92025
US

V. Phone/Fax

Practice location:
  • Phone: 760-743-1431
  • Fax: 760-743-6455
Mailing address:
  • Phone: 760-743-1431
  • Fax: 760-743-6455

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number11517
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: