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General NPI Number Information
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NPI Number | 1659233344
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Entity Type | Individual
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Provider Name | ANTAEUS T WALLER
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Gender | Male
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Dates
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Enumeration Date | 12/01/2025
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Last Update Date | 12/01/2025
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Provider Practice Location Address
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Address Line | 2811 QUEENS PLZ N
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City | LONG ISLAND CITY
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State | NY
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Zip | 11101-4172
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Country | US
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Telephone | 718-391-8300
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Fax |
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Provider Business Mailing Address
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Address Line | 20983 WHITEHALL TER
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City | QUEENS VILLAGE
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State | NY
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Zip | 11427-1722
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Country | US
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Telephone | 718-581-6102
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 996271
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License Number State | NY
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