Provider Demographics
NPI:1720413685
Name:WADDELL, SHONDA MIDDLETON (PA)
Entity Type:Individual
Prefix:
First Name:SHONDA
Middle Name:MIDDLETON
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1790 PRESIDENTIAL CIR
Mailing Address - Street 2:SUITE C
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-5688
Mailing Address - Country:US
Mailing Address - Phone:770-979-8022
Mailing Address - Fax:770-979-1098
Practice Address - Street 1:1790 PRESIDENTIAL CIR
Practice Address - Street 2:SUITE C
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-5688
Practice Address - Country:US
Practice Address - Phone:770-979-8022
Practice Address - Fax:770-979-1098
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2015-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA5256363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical