Provider Demographics
NPI:1790308278
Name:WALLIS, GREGORY (DO)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:
Last Name:WALLIS
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1031 MCINTOSH CIR
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-3643
Mailing Address - Country:US
Mailing Address - Phone:801-455-5078
Mailing Address - Fax:437-537-5094
Practice Address - Street 1:1031 MCINTOSH CIR
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-3643
Practice Address - Country:US
Practice Address - Phone:801-455-5078
Practice Address - Fax:437-537-5094
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2020-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program