Provider Demographics
NPI:1265868384
Name:WALLER, RYAN
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WALLER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:872 S 291 HWY
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:MO
Mailing Address - Zip Code:64068-2296
Mailing Address - Country:US
Mailing Address - Phone:816-415-1700
Mailing Address - Fax:816-415-1705
Practice Address - Street 1:872 S 291 HWY
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:MO
Practice Address - Zip Code:64068-2296
Practice Address - Country:US
Practice Address - Phone:816-415-1700
Practice Address - Fax:816-415-1705
Is Sole Proprietor?:No
Enumeration Date:2013-09-20
Last Update Date:2013-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013007124237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2013007124OtherHEARING AID DISPENSER LICENSE