Basic Information
| Provider Information | |||||||||
| NPI: | 1932413267 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WADDELL | ||||||||
| FirstName: | HEITH | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 517 | ||||||||
| Address2: | 713 OAK STREET | ||||||||
| City: | SUNDANCE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 827290517 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072833501 | ||||||||
| FaxNumber: | 3072832255 | ||||||||
| Practice Location | |||||||||
| Address1: | 1041 MONTGOMERY ST | ||||||||
| Address2: | |||||||||
| City: | CUSTER | ||||||||
| State: | SD | ||||||||
| PostalCode: | 577301304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6056734150 | ||||||||
| FaxNumber: | 6056733917 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2010 | ||||||||
| LastUpdateDate: | 03/31/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/31/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8880 | SD | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 135583000 | 05 | WY | MEDICAID |