Individual
RYAN R WALLACE
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
CFA
Contact information
Practice address
101 W 1ST AVE, CHEYENNE, WY 82001-1330
(970) 391-1886
Mailing address
101 W 1ST AVE, CHEYENNE, WY 82001-1330
(197) 039-1188
Taxonomy
Speciality
Code
Description
License number
State
246ZC0007X
Surgical Assistant
—
—
363AS0400X
Surgical Physician Assistant
Primary
—
—
Other
Enumeration date
05/16/2013
Last updated
09/11/2023
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