1033720073 NPI number — MR. ANTHONI AUSTIN WEDDERBURN ATC, LAT

Table of content: MR. ANTHONI AUSTIN WEDDERBURN ATC, LAT (NPI 1033720073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033720073 NPI number — MR. ANTHONI AUSTIN WEDDERBURN ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEDDERBURN
Provider First Name:
ANTHONI
Provider Middle Name:
AUSTIN
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC, LAT
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1033720073
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5501 THUNDERIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RALEIGH
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27610-5163
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-780-4758
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1401 EDWARDS MILL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
RALEIGH
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27607-0718
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-834-1625
Provider Business Practice Location Address Fax Number:
919-834-9771
Provider Enumeration Date:
08/13/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X , with the licence number:  LAT-1496 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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