Provider Demographics
NPI:1033720073
Name:WEDDERBURN, ANTHONI AUSTIN (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:ANTHONI
Middle Name:AUSTIN
Last Name:WEDDERBURN
Suffix:
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 THUNDERIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-5163
Mailing Address - Country:US
Mailing Address - Phone:919-780-4758
Mailing Address - Fax:
Practice Address - Street 1:1401 EDWARDS MILL RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-0718
Practice Address - Country:US
Practice Address - Phone:919-834-1625
Practice Address - Fax:919-834-9771
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-14962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer