Provider Demographics
NPI:1992765960
Name:WALDRON, GLEN NEAL (MSPT)
Entity type:Individual
Prefix:MR
First Name:GLEN
Middle Name:NEAL
Last Name:WALDRON
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1775 BROWNING WAY
Mailing Address - Street 2:STE 203
Mailing Address - City:ELKO
Mailing Address - State:NV
Mailing Address - Zip Code:89801-8335
Mailing Address - Country:US
Mailing Address - Phone:775-738-4494
Mailing Address - Fax:775-777-3192
Practice Address - Street 1:1775 BROWNING WAY
Practice Address - Street 2:STE 203
Practice Address - City:ELKO
Practice Address - State:NV
Practice Address - Zip Code:89801-8335
Practice Address - Country:US
Practice Address - Phone:775-738-4494
Practice Address - Fax:775-777-3192
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2015-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV1794225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVP00819160OtherRAILROAD MEDICARE PIN
NV100575Medicare UPIN
NVCK841ZMedicare PIN