Provider Demographics
NPI:1326321563
Name:WALLIS, WESLEY W (DC)
Entity Type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:W
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13430 SW SARATOGA LN
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97008-7602
Mailing Address - Country:US
Mailing Address - Phone:503-250-0914
Mailing Address - Fax:
Practice Address - Street 1:13430 SW SARATOGA LN
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97008-7602
Practice Address - Country:US
Practice Address - Phone:503-250-0914
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-23
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORN/A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor