Healthcare Provider Details

I. General information

NPI: 1215461785
Provider Name (Legal Business Name): AMANDA WADDELL D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2017
Last Update Date: 02/23/2023
Certification Date: 02/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6644 E BAYWOOD AVE
MESA AZ
85206-1797
US

IV. Provider business mailing address

6644 E BAYWOOD AVE
MESA AZ
85206-1747
US

V. Phone/Fax

Practice location:
  • Phone: 480-321-2000
  • Fax:
Mailing address:
  • Phone: 480-321-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number008718
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number008718
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: