Provider Demographics
NPI:1053854893
Name:PADDOCK, WAYNE
Entity Type:Individual
Prefix:MR
First Name:WAYNE
Middle Name:
Last Name:PADDOCK
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:WAYNE
Other - Middle Name:
Other - Last Name:PADDOCK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RDO
Mailing Address - Street 1:583 IYANNOUGH RD
Mailing Address - Street 2:
Mailing Address - City:HYANNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02601-1929
Mailing Address - Country:US
Mailing Address - Phone:508-771-2205
Mailing Address - Fax:508-778-1973
Practice Address - Street 1:583 IYANNOUGH RD
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-1929
Practice Address - Country:US
Practice Address - Phone:508-771-2205
Practice Address - Fax:508-778-1973
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1271156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician