Basic Information
| Provider Information | |||||||||
| NPI: | 1992191324 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALSH | ||||||||
| FirstName: | DIANE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2341 E PURPLE SAGE DR | ||||||||
| Address2: | |||||||||
| City: | SPANISH FORK | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846606179 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012301712 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1034 N 500 W | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013577850 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2015 | ||||||||
| LastUpdateDate: | 01/08/2019 | ||||||||
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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 | 207P00000X | MD21813 | ME | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207P00000X | 6820890-1205 | UT | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.