Provider Demographics
NPI:1508476615
Name:WALLER, ADAM (NP)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3988
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62902-3988
Mailing Address - Country:US
Mailing Address - Phone:618-937-3400
Mailing Address - Fax:618-997-9324
Practice Address - Street 1:502 W SAINT LOUIS ST STE 4
Practice Address - Street 2:
Practice Address - City:WEST FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:62896-1968
Practice Address - Country:US
Practice Address - Phone:618-937-3400
Practice Address - Fax:618-997-9324
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2022-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209021745363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner