Provider Demographics
NPI:1861919243
Name:WAKEHAM, GEORGE
Entity type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:
Last Name:WAKEHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 LATHROP AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-2275
Mailing Address - Country:US
Mailing Address - Phone:347-302-8715
Mailing Address - Fax:
Practice Address - Street 1:3391 RICHMOND AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10312-2025
Practice Address - Country:US
Practice Address - Phone:718-608-9170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-25
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY024103225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist