Provider Demographics
NPI:1043785421
Name:WEIDAUER, LEE (ATC)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:
Last Name:WEIDAUER
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 1:509 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:DELL RAPIDS
Mailing Address - State:SD
Mailing Address - Zip Code:57022-2122
Mailing Address - Country:US
Mailing Address - Phone:507-829-1631
Mailing Address - Fax:
Practice Address - Street 1:1175 MEDARY AVE S
Practice Address - Street 2:
Practice Address - City:BROOKINGS
Practice Address - State:SD
Practice Address - Zip Code:57006-3949
Practice Address - Country:US
Practice Address - Phone:605-688-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-11
Last Update Date:2018-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer