Provider Demographics
NPI:1972556447
Name:RALSTON, WALLACE EUGENE (CRNA)
Entity Type:Individual
Prefix:
First Name:WALLACE
Middle Name:EUGENE
Last Name:RALSTON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2305 SOUTH 65 HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MO
Mailing Address - Zip Code:65340-2640
Mailing Address - Country:US
Mailing Address - Phone:660-886-7431
Mailing Address - Fax:
Practice Address - Street 1:2305 S 65 HIGHWAY
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MO
Practice Address - Zip Code:65340
Practice Address - Country:US
Practice Address - Phone:660-886-3554
Practice Address - Fax:660-831-3308
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO152532367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS30004543120001Medicaid
MO918782004Medicaid
MOP00189208OtherMO RR MEDICARE NUMBER