Provider Demographics
NPI:1275585978
Name:WALLER, MICHELLE (PA)
Entity Type:Individual
Prefix:
First Name:MICHELLE
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 1:26659 PLEASANT PARK RD
Mailing Address - Street 2:
Mailing Address - City:CONIFER
Mailing Address - State:CO
Mailing Address - Zip Code:80433-7714
Mailing Address - Country:US
Mailing Address - Phone:303-647-5300
Mailing Address - Fax:
Practice Address - Street 1:26659 PLEASANT PARK RD
Practice Address - Street 2:
Practice Address - City:CONIFER
Practice Address - State:CO
Practice Address - Zip Code:80433-7714
Practice Address - Country:US
Practice Address - Phone:303-647-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA -1983207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA-1983OtherLICENSE NUMBER