Provider Demographics
NPI:1649469552
Name:WADDELL, JEREMY B (PA-C)
Entity type:Individual
Prefix:
First Name:JEREMY
Middle Name:B
Last Name:WADDELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:979 EAST 3RD STREET
Mailing Address - Street 2:SUITE 300
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37403-2187
Mailing Address - Country:US
Mailing Address - Phone:423-267-0466
Mailing Address - Fax:423-757-0866
Practice Address - Street 1:979 EAST 3RD STREET
Practice Address - Street 2:SUITE 300
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2187
Practice Address - Country:US
Practice Address - Phone:423-267-0466
Practice Address - Fax:423-757-0866
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2010-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1078363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP00469363OtherRR MEDICARE PIN
KY4000501OtherMEDICARE LAB GRP
KY7100021560Medicaid
KY37903705OtherMEDICIAD LAB GRP
KY37903705OtherMEDICIAD LAB GRP