Provider Demographics
NPI:1760835342
Name:WADDELL, EMANUEL
Entity Type:Individual
Prefix:
First Name:EMANUEL
Middle Name:
Last Name:WADDELL
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 1:4301 JONES BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20814-4712
Mailing Address - Country:US
Mailing Address - Phone:800-515-5257
Mailing Address - Fax:
Practice Address - Street 1:1035 NIDER BLVD STE 100
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23459-8701
Practice Address - Country:US
Practice Address - Phone:757-953-8244
Practice Address - Fax:757-953-8206
Is Sole Proprietor?:No
Enumeration Date:2016-07-19
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138266363LF0000X
TX790297163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse