Provider Demographics
NPI:1548541113
Name:WADDLE, BRANDON MARSHALL (PTA)
Entity type:Individual
Prefix:
First Name:BRANDON
Middle Name:MARSHALL
Last Name:WADDLE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5433 STATE ROAD 46
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771
Mailing Address - Country:US
Mailing Address - Phone:877-322-5441
Mailing Address - Fax:
Practice Address - Street 1:5433 STATE ROAD 46
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771
Practice Address - Country:US
Practice Address - Phone:877-322-5441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA22680172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker