Healthcare Provider Details

I. General information

NPI: 1225696842
Provider Name (Legal Business Name): NICHOLAS TYLER WALSH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 11/22/2021
Certification Date: 11/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1653 W CONGRESS PKWY
CHICAGO IL
60612-3833
US

IV. Provider business mailing address

1520 S MAIN ST STE 2
DAYTON OH
45409-2643
US

V. Phone/Fax

Practice location:
  • Phone: 888-352-7874
  • Fax:
Mailing address:
  • Phone: 937-461-5815
  • Fax: 937-461-2896

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085-007-156
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: