Basic Information
| Provider Information | |||||||||
| NPI: | 1053713636 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | BEAU | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1111 11TH ST | ||||||||
| Address2: | |||||||||
| City: | HAWARDEN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510231903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7125513100 | ||||||||
| FaxNumber: | 7125513177 | ||||||||
| Practice Location | |||||||||
| Address1: | 1111 11TH ST | ||||||||
| Address2: | |||||||||
| City: | HAWARDEN | ||||||||
| State: | IA | ||||||||
| PostalCode: | 510231903 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7125513100 | ||||||||
| FaxNumber: | 7125513177 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2014 | ||||||||
| LastUpdateDate: | 08/18/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 62893-20 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MD-43267 | IA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.