Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207T00000X | Neurosurgeon | XXXXXXXXX | CO |
NPI | 1053583211 |
---|---|
Provider Name | Samuel Thomas Dunn Waller |
First Address | Anchorage, AK 99508-5231 |
Second Address | Anchorage, AK 99508-5231 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 27/03/2008 |
Last Update Date | 08/10/2019 |