Provider Demographics
NPI:1912714577
Name:WALSTON, JEBEDIAH DANIEL (FNP-C)
Entity type:Individual
Prefix:
First Name:JEBEDIAH
Middle Name:DANIEL
Last Name:WALSTON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MAPLE AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WARWICK
Mailing Address - State:NY
Mailing Address - Zip Code:10990-1023
Mailing Address - Country:US
Mailing Address - Phone:717-758-9738
Mailing Address - Fax:
Practice Address - Street 1:28 RYKOWSKI LN
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-4018
Practice Address - Country:US
Practice Address - Phone:845-692-3376
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY355499363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily