Provider Demographics
NPI:1003891920
Name:WALLACE, RYAN MICHAEL (HEALTH SERVICES TECH)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:MICHAEL
Last Name:WALLACE
Suffix:
Gender:M
Credentials:HEALTH SERVICES TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5425 CARPENTER AVE
Mailing Address - Street 2:APT A
Mailing Address - City:BUZZARDS BAY
Mailing Address - State:MA
Mailing Address - Zip Code:02542-1587
Mailing Address - Country:US
Mailing Address - Phone:508-968-6572
Mailing Address - Fax:508-968-6581
Practice Address - Street 1:5201 LEE RD
Practice Address - Street 2:
Practice Address - City:BUZZARDS BAY
Practice Address - State:MA
Practice Address - Zip Code:02542-1313
Practice Address - Country:US
Practice Address - Phone:508-968-6572
Practice Address - Fax:508-968-6581
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAB1552861146N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic