Provider Demographics
NPI:1316562317
Name:WALDRON, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:WALDRON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 PEACHTREE ST
Mailing Address - Street 2:
Mailing Address - City:EMPORIA
Mailing Address - State:VA
Mailing Address - Zip Code:23847-2520
Mailing Address - Country:US
Mailing Address - Phone:804-399-5706
Mailing Address - Fax:
Practice Address - Street 1:219 WEAVER AVE
Practice Address - Street 2:
Practice Address - City:EMPORIA
Practice Address - State:VA
Practice Address - Zip Code:23847-1248
Practice Address - Country:US
Practice Address - Phone:434-336-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-15
Last Update Date:2020-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2306605606225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant