Provider Demographics
NPI:1003993437
Name:WAXHAM, JON CHRISTOPHER (PT)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:CHRISTOPHER
Last Name:WAXHAM
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 INDUSTRIAL DR STE 210
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:DE
Mailing Address - Zip Code:19709-2803
Mailing Address - Country:US
Mailing Address - Phone:302-503-0440
Mailing Address - Fax:
Practice Address - Street 1:1004 N WALNUT ST
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:DE
Practice Address - Zip Code:19963-1244
Practice Address - Country:US
Practice Address - Phone:302-503-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ1-0003038225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDP75178Medicare UPIN
MD00B513M87Medicare ID - Type UnspecifiedPROVIDER NUMBER