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 1:825 SE BISHOP BLVD
Mailing Address - Street 2:
Mailing Address - City:PULLMAN
Mailing Address - State:WA
Mailing Address - Zip Code:99163-6075
Mailing Address - Country:US
Mailing Address - Phone:509-336-7300
Mailing Address - Fax:
Practice Address - Street 1:825 SE BISHOP BLVD
Practice Address - Street 2:
Practice Address - City:PULLMAN
Practice Address - State:WA
Practice Address - Zip Code:99163-6075
Practice Address - Country:US
Practice Address - Phone:509-336-7300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-19
Last Update Date:2024-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP61426716207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine