Provider Demographics
NPI:1518181189
Name:WADDLE, GERRY LEE JR
Entity Type:Individual
Prefix:MR
First Name:GERRY
Middle Name:LEE
Last Name:WADDLE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1747
Mailing Address - Street 2:
Mailing Address - City:DAVIDSON
Mailing Address - State:NC
Mailing Address - Zip Code:28036-1747
Mailing Address - Country:US
Mailing Address - Phone:704-582-1947
Mailing Address - Fax:
Practice Address - Street 1:209 RIDGE ROAD
Practice Address - Street 2:
Practice Address - City:DAVIDSON
Practice Address - State:NC
Practice Address - Zip Code:28035
Practice Address - Country:US
Practice Address - Phone:704-894-2806
Practice Address - Fax:704-894-2802
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC08172255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer