Provider Demographics
NPI:1871774430
Name:DUBUQUE, RON (ATC)
Entity type:Individual
Prefix:
First Name:RON
Middle Name:
Last Name:DUBUQUE
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BLOSSOM LANE
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119
Mailing Address - Country:US
Mailing Address - Phone:314-968-4737
Mailing Address - Fax:
Practice Address - Street 1:901 BLOSSOM LN
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-1213
Practice Address - Country:US
Practice Address - Phone:314-968-4737
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-23
Last Update Date:2007-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO000172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer