Healthcare Provider Details

I. General information

NPI: 1114468691
Provider Name (Legal Business Name): MICHAEL WALSH DPT, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2017
Last Update Date: 12/18/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4229 W FRONTAGE RD N
ROCHESTER MN
55901-4310
US

IV. Provider business mailing address

116 BROWNSVILLE ST NE
PRESTON MN
55965-1127
US

V. Phone/Fax

Practice location:
  • Phone: 507-322-3460
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12299
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: