Basic Information
| Provider Information | |||||||||
| NPI: | 1740256247 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | LARA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 149 MAIN ST | ||||||||
| Address2: | WINTHROP PEDIATRICS & ADOLESCENT MEDICINE, STE 1A | ||||||||
| City: | WINTHROP | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043641486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073772114 | ||||||||
| FaxNumber: | 2073776112 | ||||||||
| Practice Location | |||||||||
| Address1: | 149 MAIN ST | ||||||||
| Address2: | WINTHROP PEDIATRICS & ADOLESCENT MEDINDINE, STE 1A | ||||||||
| City: | WINTHROP | ||||||||
| State: | ME | ||||||||
| PostalCode: | 043641486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2073772114 | ||||||||
| FaxNumber: | 2073776112 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 10/16/2012 | ||||||||
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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 | 208000000X | 016464 | ME | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 431793499 | 05 | ME | MEDICAID |