=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386893089
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN T. WALSH P.A., C.D.E.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2008
-----------------------------------------------------
Last Update Date | 04/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 625 W CITRACADO PKWY SUITE 108
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-743-1431
-----------------------------------------------------
Fax | 760-743-6455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 625 W CITRACADO PKWY SUITE 108
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92025
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-743-1431
-----------------------------------------------------
Fax | 760-743-6455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 11517
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------