MEDICARE: DIANE WALSH MD

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	390200000X	Student in an Organized Health Care Education/Training Program
2	207P00000X	Emergency Medicine Physician	6820890-1205	UT
3	207P00000X	Emergency Medicine Physician	MD21813	ME

General Provider Information

NPI Number	:	1992191324
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIANE WALSH MD

Provider Business Mailing Address
First Line	:	PO BOX 30180
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84130-0180
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1034 N 500 W
Second Line	:
City	:	PROVO
State	:	UT
Zip	:	84604
Country	:	US
Telephone Number	:	801-357-7850
Fax Number	:

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

Provider Enumeration Date	:	04/13/2015
Last Update Date	:	04/14/2026

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