Healthcare Provider Details

I. General information

NPI: 1770091076
Provider Name (Legal Business Name): ALEXANDRA C WALSH PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2018
Last Update Date: 12/17/2024
Certification Date: 12/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22 S GREENE ST
BALTIMORE MD
21201-1544
US

IV. Provider business mailing address

PO BOX 64226
BALTIMORE MD
21264-4226
US

V. Phone/Fax

Practice location:
  • Phone: 667-214-1718
  • Fax: 410-706-6976
Mailing address:
  • Phone: 667-217-1734
  • Fax: 410-706-6976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number025090
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA059739
License Number StatePA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberC0009248
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: