Provider Demographics
NPI:1053878447
Name:WAKO, SIMON
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:WAKO
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 1:239 N WYCOMBE AVE
Mailing Address - Street 2:
Mailing Address - City:LANSDOWNE
Mailing Address - State:PA
Mailing Address - Zip Code:19050-1722
Mailing Address - Country:US
Mailing Address - Phone:267-266-8265
Mailing Address - Fax:
Practice Address - Street 1:239 N WYCOMBE AVE
Practice Address - Street 2:
Practice Address - City:LANSDOWNE
Practice Address - State:PA
Practice Address - Zip Code:19050-1722
Practice Address - Country:US
Practice Address - Phone:267-266-8265
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-21
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer