Provider Demographics
NPI:1679021497
Name:WALLACE, RYAN JAMES
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:JAMES
Last Name:WALLACE
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 1:3535 GRANGER RD
Mailing Address - Street 2:
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44333-1538
Mailing Address - Country:US
Mailing Address - Phone:330-331-7207
Mailing Address - Fax:330-331-7587
Practice Address - Street 1:3535 GRANGER RD
Practice Address - Street 2:
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44333-1538
Practice Address - Country:US
Practice Address - Phone:330-331-7207
Practice Address - Fax:330-331-7587
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2023-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25705363L00000X
OHAPRN.CNP.020062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH381264OtherRN