Provider Demographics
NPI:1417976689
Name:WAMBOLD, JASON M (MSPT)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:WAMBOLD
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7702 WHISPERS LN
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:NY
Mailing Address - Zip Code:14519-8701
Mailing Address - Country:US
Mailing Address - Phone:585-455-9992
Mailing Address - Fax:
Practice Address - Street 1:807 RIDGE RD STE B
Practice Address - Street 2:WEBSTER WOODS PLAZA
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-2497
Practice Address - Country:US
Practice Address - Phone:585-347-0202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028339225100000X
PA0131462251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY028339OtherLICENSE