Provider Demographics
NPI:1598214116
Name:WADDELL, CAROLYN (PA-C)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 E JOHNSON AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-6091
Mailing Address - Country:US
Mailing Address - Phone:850-477-3252
Mailing Address - Fax:
Practice Address - Street 1:2120 E JOHNSON AVE STE 100
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-6091
Practice Address - Country:US
Practice Address - Phone:850-477-3252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-23
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9109908363AM0700X
FLPA 9109908363A00000X
AL363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant