Provider Demographics
NPI:1770370488
Name:WALLACE, RYAN JOE (RT (R))
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:JOE
Last Name:WALLACE
Suffix:
Gender:
Credentials:RT (R)
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2323 CHARNITA DR
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:WA
Mailing Address - Zip Code:99403-1429
Mailing Address - Country:US
Mailing Address - Phone:208-596-8408
Mailing Address - Fax:
Practice Address - Street 1:2500 W A ST STE 201
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843-6000
Practice Address - Country:US
Practice Address - Phone:208-596-8408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID3869212085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging