Gordon Jay Wallis, LMT.

Primary specialty

SpecialistTaxonomy code 174400000X

License

101469 Issued in AK

Practice address

142 W 5TH Ave
Anchorage, AK 99501-2522

Phone

(907) 258-1122

NPI assigned

Oct 19, 2016

Sex

Male

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1476835200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1476835200000",
    "number": "1548711005",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1020 W 12TH AVE",
            "address_2": "SUITE 714",
            "city": "ANCHORAGE",
            "state": "AK",
            "postal_code": "995014577",
            "telephone_number": "907-602-9045"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "142 W 5TH AVE",
            "city": "ANCHORAGE",
            "state": "AK",
            "postal_code": "995012522",
            "telephone_number": "907-258-1122"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WALLIS",
        "first_name": "GORDON",
        "middle_name": "JAY",
        "name_prefix": "Mr.",
        "credential": "LMT.",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2016-10-19",
        "last_updated": "2016-10-19",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "174400000X",
            "taxonomy_group": "",
            "desc": "Specialist",
            "state": "AK",
            "license": "101469",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Destiny Waller
• Samuel Thomas Dunn Waller, MD
• Michael Walleri, DO
• Jeri R Wallin, EMT III
• Mackenzie G Wallin, BA
• Elizabeth Wallmann-Filley, LMSW
• Vanessa Walluk
• Walmart Inc.
• Walmart Inc.
• Walmart Inc.

• All providers in Anchorage, AK
• Specialist in Alaska

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Oct 19, 2016; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.