Healthcare Provider Details

I. General information

NPI: 1891070694
Provider Name (Legal Business Name): JENNIFER L WAITE PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/12/2011
Last Update Date: 09/03/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9825 HOSPITAL DR STE 205
MAPLE GROVE MN
55369-4480
US

IV. Provider business mailing address

2001 KILLEBREW DR STE 308
BLOOMINGTON MN
55425-1886
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-7000
  • Fax: 763-587-7015
Mailing address:
  • Phone: 651-999-7022
  • Fax: 651-999-6970

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number363AM0700X
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.004163
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13027
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: