Provider Demographics
NPI:1831194208
Name:WAMBOLD, BARRIE JO (PT)
Entity type:Individual
Prefix:
First Name:BARRIE
Middle Name:JO
Last Name:WAMBOLD
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 S BEST AVE
Mailing Address - Street 2:
Mailing Address - City:WALNUTPORT
Mailing Address - State:PA
Mailing Address - Zip Code:18088-1217
Mailing Address - Country:US
Mailing Address - Phone:610-760-1520
Mailing Address - Fax:610-760-1721
Practice Address - Street 1:421 S BEST AVE
Practice Address - Street 2:
Practice Address - City:WALNUTPORT
Practice Address - State:PA
Practice Address - Zip Code:18088-1217
Practice Address - Country:US
Practice Address - Phone:610-760-1520
Practice Address - Fax:610-760-1721
Is Sole Proprietor?:No
Enumeration Date:2005-06-14
Last Update Date:2008-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA394529Medicare ID - Type Unspecified