Provider Demographics
NPI:1871609008
Name:WAKAMATSU, JON P (MD)
Entity type:Individual
Prefix:
First Name:JON
Middle Name:P
Last Name:WAKAMATSU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ALBANY AVE
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-1530
Mailing Address - Country:US
Mailing Address - Phone:307-532-2017
Mailing Address - Fax:
Practice Address - Street 1:1441 N 12TH ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2837
Practice Address - Country:US
Practice Address - Phone:602-747-4577
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY5418A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E60629Medicare UPIN
WYW22572Medicare PIN
WYW22573Medicare PIN