Provider Demographics
NPI:1952892069
Name:WADDELL, KEITH A (DPT)
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:A
Last Name:WADDELL
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 S RIVER RD UNIT 58
Mailing Address - Street 2:
Mailing Address - City:BEDFORD
Mailing Address - State:NH
Mailing Address - Zip Code:03110-6751
Mailing Address - Country:US
Mailing Address - Phone:603-626-4205
Mailing Address - Fax:
Practice Address - Street 1:40 S RIVER RD UNIT 58
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:NH
Practice Address - Zip Code:03110-6751
Practice Address - Country:US
Practice Address - Phone:603-626-4205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPENDING2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic