Provider Demographics
NPI:1225217870
Name:WALSH, ELLEN K (PA-C)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:K
Last Name:WALSH
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:SUITE 130
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:317-963-0860
Mailing Address - Fax:
Practice Address - Street 1:550 UNIVERSITY BLVD
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5149
Practice Address - Country:US
Practice Address - Phone:317-715-6402
Practice Address - Fax:617-715-6415
Is Sole Proprietor?:No
Enumeration Date:2007-10-31
Last Update Date:2015-04-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10000569A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
INM400025479Medicare PIN
IN219950E5Medicare PIN