Provider Demographics
NPI:1063449858
Name:NORTHRUP, WAYNE THOMAS (ATC)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:THOMAS
Last Name:NORTHRUP
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 1:11350 PALMS BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90066-2104
Mailing Address - Country:US
Mailing Address - Phone:310-391-7127
Mailing Address - Fax:
Practice Address - Street 1:11350 PALMS BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90066-2104
Practice Address - Country:US
Practice Address - Phone:310-391-7127
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer