Provider Demographics
NPI:1639402019
Name:WADDLE, NATHAN
Entity Type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:WADDLE
Suffix:
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 1:14567 MOUNT CALVARY RD
Mailing Address - Street 2:
Mailing Address - City:LOOGOOTEE
Mailing Address - State:IN
Mailing Address - Zip Code:47553-4903
Mailing Address - Country:US
Mailing Address - Phone:812-709-0941
Mailing Address - Fax:866-785-4924
Practice Address - Street 1:188 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:CARMEL
Practice Address - State:IN
Practice Address - Zip Code:46032
Practice Address - Country:US
Practice Address - Phone:317-573-1037
Practice Address - Fax:866-785-4924
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN06002984A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant