Provider Demographics
NPI:1689618852
Name:WALLER, JOSEPH R (PT)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:WALLER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4000 N PROVIDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54913-8018
Mailing Address - Country:US
Mailing Address - Phone:920-257-2005
Mailing Address - Fax:920-257-2004
Practice Address - Street 1:E3277 APPLE TREE LN
Practice Address - Street 2:
Practice Address - City:WAUPACA
Practice Address - State:WI
Practice Address - Zip Code:54981-7580
Practice Address - Country:US
Practice Address - Phone:715-256-0358
Practice Address - Fax:715-256-0393
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI6231-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40319100Medicaid
WI64-07247OtherMEDICA
MN27F99WAOtherBCBS OF MN
WI64-03552OtherMEDICA
WI650023250OtherRAILROAD MEDICARE/POPLAR
WI84251OtherSECURITY HEALTH PLAN
MN42B57WAOtherBCBS OF MN
WIP00403685OtherRAILROAD MEDICARE/NEW LONDON
WI64-07247OtherMEDICA
WI000286020Medicare ID - Type Unspecified
MN42B57WAOtherBCBS OF MN
WI650023250OtherRAILROAD MEDICARE/POPLAR