Healthcare Provider Details

I. General information

NPI: 1275816274
Provider Name (Legal Business Name): BRETT MICHAEL WAITE PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/26/2011
Last Update Date: 02/03/2026
Certification Date: 02/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3815 N SCHREIBER WAY UNIT 102
COEUR D ALENE ID
83815-8434
US

IV. Provider business mailing address

3815 N SCHREIBER WAY UNIT 102
COEUR D ALENE ID
83815-8434
US

V. Phone/Fax

Practice location:
  • Phone: 208-667-4557
  • Fax: 208-765-2887
Mailing address:
  • Phone: 208-667-4557
  • Fax: 208-765-2887

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-2640
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: