Active NPI
Ryan Joe Wallace, RT (R)
- Body Imaging Physician
- Moscow, ID
National Provider Identifier
1770370488
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Body Imaging Physician
- License
- 386921
- Practice address
- 2500 W a St Ste 201
Moscow, ID 83843-6000 - Phone
- (208) 596-8408
- NPI assigned
- Apr 24, 2025
- Sex
- Male
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Body Imaging Physician | 2085B0100X | 386921 | ID | Primary |
Addresses
Primary practice location
2500 W a St Ste 201
Moscow, ID 83843-6000
Mailing address
2323 Charnita Dr
Clarkston, WA 99403-1429
Phone (208) 596-8408
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 386921 | ID | MD | Body Imaging Physician |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1745452800000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1745452800000",
"number": "1770370488",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2323 CHARNITA DR",
"city": "CLARKSTON",
"state": "WA",
"postal_code": "994031429",
"telephone_number": "208-596-8408"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2500 W A ST STE 201",
"city": "MOSCOW",
"state": "ID",
"postal_code": "838436000",
"telephone_number": "208-596-8408"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "RYAN",
"middle_name": "JOE",
"credential": "RT (R)",
"sole_proprietor": "YES",
"sex": "M",
"enumeration_date": "2025-04-24",
"last_updated": "2025-04-24",
"certification_date": "2025-04-24",
"status": "A"
},
"taxonomies": [
{
"code": "2085B0100X",
"taxonomy_group": "",
"desc": "Radiology, Body Imaging",
"state": "ID",
"license": "386921",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Moscow, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 24, 2025; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.