Individual
MR. GORDON JAY WALLIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
LMT.
Contact information
Practice address
142 W 5TH AVE, ANCHORAGE, AK 99501-2522
(907) 258-1122
Mailing address
1020 W 12TH AVE, SUITE 714, ANCHORAGE, AK 99501-4577
(907) 602-9045
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
Primary
101469
AK
Other
Enumeration date
10/19/2016
Last updated
10/19/2016
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