Provider Demographics
NPI:1881097624
Name:WADDELL, JEREMY (NP-C)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:
Last Name:WADDELL
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8914A REED DR
Mailing Address - Street 2:
Mailing Address - City:EMERALD ISLE
Mailing Address - State:NC
Mailing Address - Zip Code:28594-2462
Mailing Address - Country:US
Mailing Address - Phone:252-764-2024
Mailing Address - Fax:252-764-2376
Practice Address - Street 1:8914A REED DR
Practice Address - Street 2:
Practice Address - City:EMERALD ISLE
Practice Address - State:NC
Practice Address - Zip Code:28594-2462
Practice Address - Country:US
Practice Address - Phone:252-764-2024
Practice Address - Fax:252-764-2376
Is Sole Proprietor?:No
Enumeration Date:2014-10-08
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5007249363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health