Basic Information
| Provider Information | |||||||||
| NPI: | 1497032932 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | MALLORY | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 79777 | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 212790777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547794 | ||||||||
| FaxNumber: | 4346547582 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 MARTHA JEFFERSON DR | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4346547580 | ||||||||
| FaxNumber: | 4346547582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2011 | ||||||||
| LastUpdateDate: | 07/03/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 0110004076 | VA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.