Basic Information
| Provider Information | |||||||||
| NPI: | 1669412615 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMILTON | ||||||||
| FirstName: | WALTER | ||||||||
| MiddleName: | VINCENT | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MSN;CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5795 STONEY BROOK RD | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490097700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692174781 | ||||||||
| FaxNumber: | 2693273168 | ||||||||
| Practice Location | |||||||||
| Address1: | 818 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | ADRIAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492211446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172650900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 03/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 4704222557 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 0N37190 | 01 | MI | GRP BCBS NUMBER | OTHER |