Healthcare Provider Details

I. General information

NPI: 1477538155
Provider Name (Legal Business Name): WALLACE J HAYASAKA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 HIGHLAND BLVD
BOZEMAN MT
59715-6902
US

IV. Provider business mailing address

PO BOX 84891
SEATTLE WA
98124-6191
US

V. Phone/Fax

Practice location:
  • Phone: 602-262-8900
  • Fax: 602-262-4132
Mailing address:
  • Phone: 406-414-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number57767
License Number StateMT
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number52953
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number38727
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: