Healthcare Provider Details

I. General information

NPI: 1992191324
Provider Name (Legal Business Name): DIANE WALSH MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 04/14/2026
Certification Date: 04/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N 500 W
PROVO UT
84604
US

IV. Provider business mailing address

PO BOX 30180
SALT LAKE CITY UT
84130-0180
US

V. Phone/Fax

Practice location:
  • Phone: 801-357-7850
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number6820890-1205
License Number StateUT
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD21813
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: