Provider Demographics
NPI:1285928432
Name:WALLER, EVA JAYNE (MD)
Entity type:Individual
Prefix:
First Name:EVA
Middle Name:JAYNE
Last Name:WALLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 CHILDRENS LN
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23507-1910
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:601 CHILDRENS LN
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1910
Practice Address - Country:US
Practice Address - Phone:757-668-7320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-06
Last Update Date:2024-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01079207L00000X
VA0101278464207LP3000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207LP3000XAllopathic & Osteopathic PhysiciansAnesthesiologyPediatric AnesthesiologyGroup - Multi-Specialty
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology