MEDICARE: MADISON VARANDA WRIBORG

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2025030201	MO

General Provider Information

NPI Number	:	1417751462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MADISON VARANDA WRIBORG

Provider Business Mailing Address
First Line	:	8680 DELMAR BLVD APT 553
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63124-2337
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2497 CREVE COEUR MILL RD
Second Line	:
City	:	MARYLAND HEIGHTS
State	:	MO
Zip	:	63043-1199
Country	:	US
Telephone Number	:	314-213-8051
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/01/2025
Last Update Date	:	04/20/2026

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Directions to “ MADISON VARANDA WRIBORG ” Practice Location

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