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General NPI Number Information
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NPI Number | 1912714577
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Entity Type | Individual
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Provider Name | JEBEDIAH DANIEL WALSTON FNP-C
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Gender | Male
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Dates
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Enumeration Date | 12/16/2024
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Last Update Date | 12/16/2024
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Provider Practice Location Address
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Address Line | 28 RYKOWSKI LN
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City | MIDDLETOWN
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State | NY
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Zip | 10941-4018
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Country | US
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Telephone | 845-692-3376
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Fax |
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Provider Business Mailing Address
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Address Line | 50 MAPLE AVE APT 1
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City | WARWICK
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State | NY
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Zip | 10990-1023
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Country | US
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Telephone | 717-758-9738
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 355499
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License Number State | NY
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