Healthcare Provider Details

I. General information

NPI: 1073950440
Provider Name (Legal Business Name): JASON WAITE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/25/2013
Last Update Date: 01/02/2024
Certification Date: 01/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1257 PAIUTE CIR
LAS VEGAS NV
89106-3202
US

IV. Provider business mailing address

PO BOX 110
CASTLE DALE UT
84513-0110
US

V. Phone/Fax

Practice location:
  • Phone: 516-506-8839
  • Fax:
Mailing address:
  • Phone: 516-506-8839
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number9114085-0501
License Number StateUT
# 2
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number9114085-0501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: