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General NPI Number Information
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NPI Number | 1649469552
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Entity Type | Individual
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Provider Name | JEREMY B. WADDELL P.A.-C.
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Gender | Male
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Dates
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Enumeration Date | 10/16/2007
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Last Update Date | 10/15/2010
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Provider Practice Location Address
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Address Line | 979 EAST 3RD STREET SUITE 300
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City | CHATTANOOGA
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State | TN
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Zip | 37403-2187
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Country | US
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Telephone | 423-267-0466
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Fax | 423-757-0866
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Provider Business Mailing Address
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Address Line | 979 EAST 3RD STREET SUITE 300
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City | CHATTANOOGA
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State | TN
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Zip | 37403-2187
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Country | US
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Telephone | 423-267-0466
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Fax | 423-757-0866
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA1078
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA1078
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License Number State | KY
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