Basic Information
| Provider Information | |||||||||
| NPI: | 1801324264 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WALLER | ||||||||
| FirstName: | JONATHAN | ||||||||
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| Credential: | MD/MPH | ||||||||
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| Mailing Information | |||||||||
| Address1: | 365 SILAS CT | ||||||||
| Address2: | |||||||||
| City: | BENICIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945103959 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2700 NW STEWART PKWY | ||||||||
| Address2: | |||||||||
| City: | ROSEBURG | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974711281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5416730611 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2017 | ||||||||
| LastUpdateDate: | 09/18/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 198799 | OR | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 198799 | OR | N | Allopathic & Osteopathic Physicians | Hospitalist | 207R00000X | A167405 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.