Provider Demographics
NPI:1871850321
Name:WALLER, CHRISTOPHER SCOTT (IDC)
Entity type:Individual
Prefix:MR
First Name:CHRISTOPHER
Middle Name:SCOTT
Last Name:WALLER
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:937 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93246-4700
Mailing Address - Country:US
Mailing Address - Phone:559-998-4384
Mailing Address - Fax:
Practice Address - Street 1:4755 PASTURE RD BLDG 299
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89496-3202
Practice Address - Country:US
Practice Address - Phone:775-426-3125
Practice Address - Fax:775-426-3135
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-20
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman