MEDICARE: JUAN WALLER PTA

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	225200000X	Physical Therapy Assistant	PTA002005	GA

General Provider Information

NPI Number	:	1780763425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN WALLER PTA

Provider Business Mailing Address
First Line	:	PO BOX 518
Second Line	:
City	:	JONESBORO
State	:	GA
Zip	:	30237-0518
Country	:	US
Telephone Number	:	770-631-8277
Fax Number	:	770-631-9403

Provider Business Practice Location Address
First Line	:	1901 PHOENIX BLVD
Second Line	:	SUITE 205
City	:	COLLEGE PARK
State	:	GA
Zip	:	30349-5588
Country	:	US
Telephone Number	:	770-502-1023
Fax Number	:

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

Provider Enumeration Date	:	11/03/2006
Last Update Date	:	07/08/2007

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