Provider Demographics
NPI:1063800704
Name:WADDELL, RYAN WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:WILLIAM
Last Name:WADDELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10995 CLUB WEST PKWY STE 400
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5862
Mailing Address - Country:US
Mailing Address - Phone:763-400-4940
Mailing Address - Fax:
Practice Address - Street 1:10995 CLUB WEST PKWY STE 400
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5862
Practice Address - Country:US
Practice Address - Phone:763-400-4940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-05
Last Update Date:2015-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6017111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor