Provider Demographics
NPI:1942428701
Name:WALSH, SUSAN J (CRNA)
Entity type:Individual
Prefix:MS
First Name:SUSAN
Middle Name:J
Last Name:WALSH
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 WALNUT PL
Mailing Address - Street 2:
Mailing Address - City:ALLENDALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07401-1912
Mailing Address - Country:US
Mailing Address - Phone:201-760-6485
Mailing Address - Fax:973-972-2357
Practice Address - Street 1:50 WALNUT PL
Practice Address - Street 2:
Practice Address - City:ALLENDALE
Practice Address - State:NJ
Practice Address - Zip Code:07401-1912
Practice Address - Country:US
Practice Address - Phone:201-760-6485
Practice Address - Fax:973-972-2357
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NO07735600367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ046231Medicare ID - Type Unspecified