Provider Demographics
NPI:1477538155
Name:HAYASAKA, WALLACE J (MD)
Entity type:Individual
Prefix:DR
First Name:WALLACE
Middle Name:J
Last Name:HAYASAKA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 84891
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-6191
Mailing Address - Country:US
Mailing Address - Phone:406-414-5000
Mailing Address - Fax:
Practice Address - Street 1:915 HIGHLAND BLVD
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6902
Practice Address - Country:US
Practice Address - Phone:602-262-8900
Practice Address - Fax:602-262-4132
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT57767207L00000X
AZ52953207L00000X
CO38727207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO26353580Medicaid
COCW6838Medicare PIN