Provider Demographics
NPI:1962419473
Name:AYRES, BRUCE WALLACE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:WALLACE
Last Name:AYRES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:705 GAGE BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-9716
Mailing Address - Country:US
Mailing Address - Phone:509-374-4400
Mailing Address - Fax:509-374-4440
Practice Address - Street 1:705 GAGE BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-9716
Practice Address - Country:US
Practice Address - Phone:509-374-4400
Practice Address - Fax:509-374-4440
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-10-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00043560208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1120526Medicaid
WA8808495Medicare ID - Type UnspecifiedBRUCE W. AYRES, MD
WAG21291Medicare UPIN
WA1120526Medicaid