MEDICARE: RYAN WALLACE P.T., D.P.T.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	11914	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	86-0977426	OTHER	AZ	TAX ID

General Provider Information

NPI Number	:	1154795078
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RYAN WALLACE P.T., D.P.T.

Provider Business Mailing Address
First Line	:	10852 N GUAVA DR
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85737-6500
Country	:	US
Telephone Number	:	520-245-2193
Fax Number	:

Provider Business Practice Location Address
First Line	:	5501 N ORACLE RD STE 101
Second Line	:
City	:	TUCSON
State	:	AZ
Zip	:	85704-3850
Country	:	US
Telephone Number	:	520-408-9547
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/16/2015
Last Update Date	:	11/16/2015

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