Healthcare Provider Details

I. General information

NPI: 1003133570
Provider Name (Legal Business Name): WALTER RAE RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 04/23/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 BIG DEER RUN
NEWFANE VT
05345-9570
US

IV. Provider business mailing address

58 BIG DEER RUN
NEWFANE VT
05345-9570
US

V. Phone/Fax

Practice location:
  • Phone: 802-365-9499
  • Fax:
Mailing address:
  • Phone: 802-365-9499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC0060X
TaxonomyCritical Access Hospital
License Number0260058372
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: