Provider Demographics
NPI:1083149231
Name:EDGERTON, GLENN (EDD, LAT)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:
Last Name:EDGERTON
Suffix:
Gender:M
Credentials:EDD, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 15094
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86011-0543
Mailing Address - Country:US
Mailing Address - Phone:928-523-6837
Mailing Address - Fax:
Practice Address - Street 1:1705 N SAN FRANCISCO ST
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-1348
Practice Address - Country:US
Practice Address - Phone:928-523-6837
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ10792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer