Provider Demographics
NPI:1831494525
Name:WALLER, ROBERT (MS, ATC, LAT, NASM)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:MS, ATC, LAT, NASM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10651 WILSHIRE AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87122-3160
Mailing Address - Country:US
Mailing Address - Phone:307-766-2323
Mailing Address - Fax:
Practice Address - Street 1:10651 WILSHIRE AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87122-3160
Practice Address - Country:US
Practice Address - Phone:307-766-2323
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-11
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM5902255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty