Healthcare Provider Details

I. General information

NPI: 1518130194
Provider Name (Legal Business Name): HUGH DURWOOD WALLER II PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2008
Last Update Date: 06/15/2021
Certification Date: 06/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 S MAIN ST
RUTLAND VT
05701-4713
US

IV. Provider business mailing address

74 PLEASANT ST STE 204
NEW LONDON NH
03257-5881
US

V. Phone/Fax

Practice location:
  • Phone: 802-772-4165
  • Fax: 802-855-8489
Mailing address:
  • Phone: 603-526-4635
  • Fax: 603-526-2151

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: