Basic Information
| Provider Information | |||||||||
| NPI: | 1285756577 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | THOMAS | ||||||||
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| Credential: | A.N.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER ST | ||||||||
| Address2: | 2ND FLOOR CRED DEPT | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 4771 HYLAN BLVD | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 10312 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189488200 | ||||||||
| FaxNumber: | 7184202718 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/06/2007 | ||||||||
| LastUpdateDate: | 10/01/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 306239 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 03512961 | 05 | NY | MEDICAID |