Provider Demographics
NPI:1790371235
Name:WAKEMAN, COLIN JOHN (ATC)
Entity type:Individual
Prefix:
First Name:COLIN
Middle Name:JOHN
Last Name:WAKEMAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4406 CORTEZ DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-5309
Mailing Address - Country:US
Mailing Address - Phone:703-586-2968
Mailing Address - Fax:
Practice Address - Street 1:1 JOHN MARSHALL DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25755-0002
Practice Address - Country:US
Practice Address - Phone:304-696-3170
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-18
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA20000355962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer