Healthcare Provider Details

I. General information

NPI: 1255243085
Provider Name (Legal Business Name): NATHAN WALLER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2026
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 POLY DR
BILLINGS MT
59102-1739
US

IV. Provider business mailing address

1012 HILLSIDE CIR
VERONA WI
53593-8375
US

V. Phone/Fax

Practice location:
  • Phone: 406-657-1190
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1247861
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: