Healthcare Provider Details

I. General information

NPI: 1215222708
Provider Name (Legal Business Name): JEREMY JAY WALDO CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 06/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 COUNTY ROAD 11 NW
PINE ISLAND MN
55963-9756
US

IV. Provider business mailing address

111 COUNTY ROAD 11 NW
PINE ISLAND MN
55963-9756
US

V. Phone/Fax

Practice location:
  • Phone: 507-356-4929
  • Fax:
Mailing address:
  • Phone: 507-356-4929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR1432965
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: