Healthcare Provider Details

I. General information

NPI: 1003891920
Provider Name (Legal Business Name): RYAN MICHAEL WALLACE HEALTH SERVICES TECH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5201 LEE RD
BUZZARDS BAY MA
02542-1313
US

IV. Provider business mailing address

5425 CARPENTER AVE APT A
BUZZARDS BAY MA
02542-1587
US

V. Phone/Fax

Practice location:
  • Phone: 508-968-6572
  • Fax: 508-968-6581
Mailing address:
  • Phone: 508-968-6572
  • Fax: 508-968-6581

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB1552861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: