Provider Demographics
NPI:1003820275
Name:WALES, ROBERT ALAN (MD, FACC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALAN
Last Name:WALES
Suffix:
Gender:M
Credentials:MD, FACC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 331
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0331
Mailing Address - Country:US
Mailing Address - Phone:509-747-2455
Mailing Address - Fax:509-227-7070
Practice Address - Street 1:2315 8TH ST GRADE
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:509-455-8820
Practice Address - Fax:509-227-7070
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-8366207RC0000X
WAMD00040353207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA060064955OtherRRB
WA8283913Medicaid
ID806097900Medicaid
ID806097900Medicaid
ID1101935Medicare PIN
WAGAB24475Medicare PIN