Provider Demographics
NPI:1548711005
Name:WALLIS, GORDON JAY (LMT)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:JAY
Last Name:WALLIS
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 W 12TH AVE
Mailing Address - Street 2:SUITE 714
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99501-4577
Mailing Address - Country:US
Mailing Address - Phone:907-602-9045
Mailing Address - Fax:
Practice Address - Street 1:142 W 5TH AVE
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99501-2522
Practice Address - Country:US
Practice Address - Phone:907-258-1122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK101469174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist