Provider Demographics
NPI:1194742205
Name:VARDIMAN, JOHN PHILLIP (ATC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:PHILLIP
Last Name:VARDIMAN
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 1:1301 SUNNYSIDE AVE
Mailing Address - Street 2:161- D ROBINSON GYMNASIUM
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66045-7567
Mailing Address - Country:US
Mailing Address - Phone:785-864-0709
Mailing Address - Fax:
Practice Address - Street 1:1301 SUNNYSIDE AVE
Practice Address - Street 2:161- D ROBINSON GYMNASIUM
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66045-7567
Practice Address - Country:US
Practice Address - Phone:785-864-0709
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS004832255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer