Healthcare Provider Details

I. General information

NPI: 1295676294
Provider Name (Legal Business Name): RYAN WALLACE MA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2026
Last Update Date: 04/03/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 W GOWE ST
KENT WA
98032-5892
US

IV. Provider business mailing address

3724 S BRANDON ST
SEATTLE WA
98118-6128
US

V. Phone/Fax

Practice location:
  • Phone: 253-833-7444
  • Fax:
Mailing address:
  • Phone: 253-653-2891
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberMAC.CM.70084394
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: