Healthcare Provider Details

I. General information

NPI: 1285928432
Provider Name (Legal Business Name): EVA JAYNE WALLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2011
Last Update Date: 11/03/2024
Certification Date: 11/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

IV. Provider business mailing address

601 CHILDRENS LN
NORFOLK VA
23507-1910
US

V. Phone/Fax

Practice location:
  • Phone: 757-668-7320
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number2016-01079
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number0101278464
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: