Healthcare Provider Details

I. General information

NPI: 1831494525
Provider Name (Legal Business Name): ROBERT WALLER MS, ATC, LAT, NASM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/11/2011
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10651 WILSHIRE AVE NE
ALBUQUERQUE NM
87122-3160
US

IV. Provider business mailing address

800 BRADBURY DR SE STE 116
ALBUQUERQUE NM
87106-4310
US

V. Phone/Fax

Practice location:
  • Phone: 307-766-2323
  • Fax:
Mailing address:
  • Phone: 505-272-1476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number590
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: