Provider Demographics
NPI:1083412720
Name:KLESS, WAKE ADAM
Entity type:Individual
Prefix:
First Name:WAKE
Middle Name:ADAM
Last Name:KLESS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 HAZELMERE AVE
Mailing Address - Street 2:
Mailing Address - City:MACHIAS
Mailing Address - State:NY
Mailing Address - Zip Code:14101-9763
Mailing Address - Country:US
Mailing Address - Phone:716-474-1377
Mailing Address - Fax:
Practice Address - Street 1:2245 W STATE ST
Practice Address - Street 2:
Practice Address - City:OLEAN
Practice Address - State:NY
Practice Address - Zip Code:14760-1921
Practice Address - Country:US
Practice Address - Phone:716-373-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY054026225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist