Provider Demographics
NPI:1164408100
Name:WAEDEKIN, VICKI LYNN (PA)
Entity Type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:WAEDEKIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:VICKI
Other - Middle Name:L
Other - Last Name:BECK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:144 E SUMMIT AVE
Mailing Address - Street 2:
Mailing Address - City:WALES
Mailing Address - State:WI
Mailing Address - Zip Code:53183-9546
Mailing Address - Country:US
Mailing Address - Phone:262-968-6161
Mailing Address - Fax:
Practice Address - Street 1:144 E SUMMIT AVE
Practice Address - Street 2:
Practice Address - City:WALES
Practice Address - State:WI
Practice Address - Zip Code:53183-9546
Practice Address - Country:US
Practice Address - Phone:262-968-6161
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI923-023363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42981900Medicaid
WI0028Medicare ID - Type Unspecified
WI42981900Medicaid