Healthcare Provider Details

I. General information

NPI: 1548695075
Provider Name (Legal Business Name): DR. RYAN MYLES WALLACE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3760 PIPER ST STE 1108
ANCHORAGE AK
99508-4683
US

IV. Provider business mailing address

PO BOX 31001-4162
PASADENA CA
91110-4162
US

V. Phone/Fax

Practice location:
  • Phone: 907-212-6900
  • Fax: 907-212-6936
Mailing address:
  • Phone: 866-747-2455
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number55490
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number158491
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number55490
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number158491
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: