Provider Demographics
NPI:1093982647
Name:WALLER, NANCY (PA)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:
Last Name:WALLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 S PUEBLO BLVD
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81005-1508
Mailing Address - Country:US
Mailing Address - Phone:719-647-5831
Mailing Address - Fax:719-647-5833
Practice Address - Street 1:1339 S PUEBLO BLVD
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81005-1508
Practice Address - Country:US
Practice Address - Phone:719-647-5831
Practice Address - Fax:719-647-5833
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-13
Last Update Date:2008-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO120363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical