Provider Demographics
NPI:1154452217
Name:MACKINNON, WALTER J (CRNA)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:J
Last Name:MACKINNON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 COMMERCE DR
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10801-5214
Mailing Address - Country:US
Mailing Address - Phone:914-637-3510
Mailing Address - Fax:914-819-0061
Practice Address - Street 1:1300 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-1628
Practice Address - Country:US
Practice Address - Phone:518-268-5554
Practice Address - Fax:518-268-5396
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY257009367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB7051Medicare PIN