Healthcare Provider Details

I. General information

NPI: 1295664696
Provider Name (Legal Business Name): DEREK WAX
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2026
Last Update Date: 05/14/2026
Certification Date: 05/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 S BROADWAY STE B
MINOT ND
58701-4403
US

IV. Provider business mailing address

1650 LYNDON FARM CT STE 300
LOUISVILLE KY
40223-5005
US

V. Phone/Fax

Practice location:
  • Phone: 701-852-5040
  • Fax: 701-852-5045
Mailing address:
  • Phone: 726-202-3039
  • Fax: 210-978-5592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2857
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: