Basic Information
| Provider Information | |||||||||
| NPI: | 1285678680 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | STEPHEN | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6925 SHALLOWFORD RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238940432 | ||||||||
| FaxNumber: | 4238940475 | ||||||||
| Practice Location | |||||||||
| Address1: | 6925 SHALLOWFORD RD | ||||||||
| Address2: | SUITE 206 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374211787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238940432 | ||||||||
| FaxNumber: | 4238940475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 10/06/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA0000000545 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 1285678680 | 01 | TN | NPI | OTHER |