Provider Demographics
NPI:1417751462
Name:WRIBORG, MADISON VARANDA
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:VARANDA
Last Name:WRIBORG
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8680 DELMAR BLVD APT 252
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2497 CREVE COEUR MILL RD
Practice Address - Street 2:
Practice Address - City:MARYLAND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63043-1199
Practice Address - Country:US
Practice Address - Phone:314-213-8051
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-01
Last Update Date:2025-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program