MEDICARE: GAYTHA WALLER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246RM2200X	Medical Laboratory Technician

General Provider Information

NPI Number	:	1336255637
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAYTHA WALLER

Provider Business Mailing Address
First Line	:	505 RUTH ST
Second Line	:
City	:	BAYTOWN
State	:	TX
Zip	:	77520-4807
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2002 HOLCOMBE BLVD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77030-4211
Country	:	US
Telephone Number	:	713-794-7319
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/21/2006
Last Update Date	:	07/08/2007

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