Healthcare Provider Details

I. General information

NPI: 1790224871
Provider Name (Legal Business Name): ALVIN WALSH III NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 12/20/2022
Certification Date: 12/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12330 ASHLEY DR
GULFPORT MS
39503-2737
US

IV. Provider business mailing address

2101 HIGHWAY 90
GAUTIER MS
39553-5340
US

V. Phone/Fax

Practice location:
  • Phone: 228-832-9038
  • Fax: 228-832-9990
Mailing address:
  • Phone: 228-497-7576
  • Fax: 228-497-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number901904
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: