Provider Demographics
NPI:1427628098
Name:WADDELL, DANIEL PATRICK (PA)
Entity type:Individual
Prefix:MR
First Name:DANIEL
Middle Name:PATRICK
Last Name:WADDELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:218 FOUST ST STE C
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5476
Mailing Address - Country:US
Mailing Address - Phone:336-625-2333
Mailing Address - Fax:336-625-5511
Practice Address - Street 1:525 W SWANNANOA AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3136
Practice Address - Country:US
Practice Address - Phone:336-622-4850
Practice Address - Fax:336-622-4855
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-28
Last Update Date:2022-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC001012527363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1427628098Medicaid