Provider Demographics
NPI:1245734805
Name:WALLER, ALGERNON ANTHONY STEPHEN
Entity Type:Individual
Prefix:MR
First Name:ALGERNON
Middle Name:ANTHONY STEPHEN
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 DENMARK CT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-4734
Mailing Address - Country:US
Mailing Address - Phone:631-334-9572
Mailing Address - Fax:631-629-6945
Practice Address - Street 1:68 S SERVICE RD STE 100
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2350
Practice Address - Country:US
Practice Address - Phone:631-629-2493
Practice Address - Fax:631-629-6945
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver