1477538155 NPI number — DR. WALLACE J HAYASAKA M.D.

Table of content: DR. WALLACE J HAYASAKA M.D. (NPI 1477538155)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477538155 NPI number — DR. WALLACE J HAYASAKA M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HAYASAKA
Provider First Name:
WALLACE
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477538155
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 84891
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEATTLE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98124-6191
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-414-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
915 HIGHLAND BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOZEMAN
Provider Business Practice Location Address State Name:
MT
Provider Business Practice Location Address Postal Code:
59715-6902
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
602-262-8900
Provider Business Practice Location Address Fax Number:
602-262-4132
Provider Enumeration Date:
12/14/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207L00000X , with the licence number:  57767 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207L00000X , with the licence number: 52953 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207L00000X , with the licence number: 38727 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 26353580 , issued by the state of ( CO ) . This identifiers is of the category "MEDICAID".