Provider Demographics
NPI:1033822671
Name:WALL-O'MARA, RYAN
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WALL-O'MARA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45211 HELM ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-6023
Mailing Address - Country:US
Mailing Address - Phone:734-525-9712
Mailing Address - Fax:
Practice Address - Street 1:45211 HELM ST
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-6023
Practice Address - Country:US
Practice Address - Phone:734-525-9712
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVLP002242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist