Provider Demographics
NPI:1962873711
Name:WALLER, LEAH M (PA)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:WALLER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:M
Other - Last Name:MEADOWS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 407
Mailing Address - Street 2:
Mailing Address - City:VIDALIA
Mailing Address - State:GA
Mailing Address - Zip Code:30475-0407
Mailing Address - Country:US
Mailing Address - Phone:912-537-4986
Mailing Address - Fax:
Practice Address - Street 1:1 MEADOWS PKWY
Practice Address - Street 2:
Practice Address - City:VIDALIA
Practice Address - State:GA
Practice Address - Zip Code:30474-8759
Practice Address - Country:US
Practice Address - Phone:912-535-5800
Practice Address - Fax:912-535-5830
Is Sole Proprietor?:No
Enumeration Date:2015-10-19
Last Update Date:2019-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA007734363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical