Healthcare Provider Details

I. General information

NPI: 1396884219
Provider Name (Legal Business Name): KEIRAN WALSH LLANEZA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/06/2007
Last Update Date: 04/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3125 SPRINGBANK LN SUITE E
CHARLOTTE NC
28226-3378
US

IV. Provider business mailing address

PO BOX 602148
CHARLOTTE NC
28260-2148
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-3510
  • Fax: 704-540-3668
Mailing address:
  • Phone: 704-381-3510
  • Fax: 704-540-3668

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number100392
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-00392
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: