Healthcare Provider Details

I. General information

NPI: 1063418895
Provider Name (Legal Business Name): WALTER CLINTON ROCKENSTIRE III R.N., NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 HOLLAND AVE
ALBANY NY
12208-3410
US

IV. Provider business mailing address

30 ABLEMAN AVE
ALBANY NY
12203-4827
US

V. Phone/Fax

Practice location:
  • Phone: 518-626-5349
  • Fax: 518-626-5407
Mailing address:
  • Phone: 518-869-0917
  • Fax: 518-626-5407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number330735
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: