Healthcare Provider Details

I. General information

NPI: 1265938294
Provider Name (Legal Business Name): NICHOLAS WALER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2018
Last Update Date: 03/20/2023
Certification Date: 03/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 RIDGE. AVE. DEPT. OF ANESTHESIOLOGY
EVANSTON IL
60201
US

IV. Provider business mailing address

2650 RIDGE. AVE. DEPT. OF ANESTHESIOLOGY
EVANSTON IL
60201
US

V. Phone/Fax

Practice location:
  • Phone: 847-570-2760
  • Fax:
Mailing address:
  • Phone: 847-570-2760
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number125.076418
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number036161348
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: