Provider Demographics
NPI:1003133570
Name:RAE, WALTER (RN)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:RAE
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:58 BIG DEER RUN
Mailing Address - Street 2:
Mailing Address - City:NEWFANE
Mailing Address - State:VT
Mailing Address - Zip Code:05345-9570
Mailing Address - Country:US
Mailing Address - Phone:802-365-9499
Mailing Address - Fax:
Practice Address - Street 1:58 BIG DEER RUN
Practice Address - Street 2:
Practice Address - City:NEWFANE
Practice Address - State:VT
Practice Address - Zip Code:05345-9570
Practice Address - Country:US
Practice Address - Phone:802-365-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-23
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT0260058372282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39911600Medicaid