MEDICARE: JUSTIN MICHAEL WALSH LMP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	MA00015947	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0155950	OTHER	WA	LABOR AND INDUSTRIES

General Provider Information

NPI Number	:	1912025396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTIN MICHAEL WALSH LMP

Provider Business Mailing Address
First Line	:	2152 N 112TH ST UNIT 308
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98133-8599
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1422 HARVARD AVE
Second Line	:
City	:	SEATTLE
State	:	WA
Zip	:	98122-3813
Country	:	US
Telephone Number	:	206-465-3504
Fax Number	:	206-365-3433

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/26/2007
Last Update Date	:	07/08/2007

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