Provider Demographics
NPI:1306135009
Name:WALDRON, SHAUN (ATC, LMT)
Entity type:Individual
Prefix:
First Name:SHAUN
Middle Name:
Last Name:WALDRON
Suffix:
Gender:M
Credentials:ATC, LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5496 E TAFT RD STE C
Mailing Address - Street 2:
Mailing Address - City:NORTH SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13212-3784
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5496 E TAFT RD STE C
Practice Address - Street 2:
Practice Address - City:NORTH SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13212-3784
Practice Address - Country:US
Practice Address - Phone:315-251-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-04
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0019112255A2300X
NY024785225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist