Provider Demographics
NPI:1285678680
Name:WALLER, STEPHEN C (PA)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:C
Last Name:WALLER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6925 SHALLOWFORD RD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1787
Mailing Address - Country:US
Mailing Address - Phone:423-894-0432
Mailing Address - Fax:423-894-0475
Practice Address - Street 1:6925 SHALLOWFORD RD
Practice Address - Street 2:SUITE 206
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1787
Practice Address - Country:US
Practice Address - Phone:423-894-0432
Practice Address - Fax:423-894-0475
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TNPA0000000545363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1285678680OtherNPI
TN1016710001Medicare NSC
P15987Medicare UPIN