Provider Demographics
NPI:1700883782
Name:WALDRON, AUDREY M (PT)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:M
Last Name:WALDRON
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5387 MANHATTAN CIR
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80303-4284
Mailing Address - Country:US
Mailing Address - Phone:303-543-7878
Mailing Address - Fax:303-543-7676
Practice Address - Street 1:5387 MANHATTAN CIR
Practice Address - Street 2:SUITE 100A
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-4284
Practice Address - Country:US
Practice Address - Phone:303-543-7878
Practice Address - Fax:303-543-7676
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3455225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO477138Medicare ID - Type UnspecifiedPROVIDER #
CO477148Medicare PIN