Provider Demographics
NPI:1639494560
Name:IWACHIW, WALTER (RN)
Entity Type:Individual
Prefix:MR
First Name:WALTER
Middle Name:
Last Name:IWACHIW
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 1:4835 41ST ST
Mailing Address - Street 2:
Mailing Address - City:SUNNYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11104-3121
Mailing Address - Country:US
Mailing Address - Phone:631-731-1599
Mailing Address - Fax:
Practice Address - Street 1:4835 41ST ST
Practice Address - Street 2:
Practice Address - City:SUNNYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11104-3121
Practice Address - Country:US
Practice Address - Phone:631-731-1599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-04
Last Update Date:2010-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY611627-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse