Healthcare Provider Details

I. General information

NPI: 1083663967
Provider Name (Legal Business Name): LAWRENCE WESLEY WAITE D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2006
Last Update Date: 05/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2110 EVENSON DR
ONALASKA WI
54650-8772
US

IV. Provider business mailing address

2110 EVENSON DR
ONALASKA WI
54650-8772
US

V. Phone/Fax

Practice location:
  • Phone: 608-397-6678
  • Fax: 608-781-5576
Mailing address:
  • Phone: 608-397-6678
  • Fax: 608-781-5576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number40617
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number03005
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code204C00000X
TaxonomySports Medicine (Neuromusculoskeletal Medicine) Physician
License Number036-063775
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code204D00000X
TaxonomyNeuromusculoskeletal Medicine & OMM Physician
License Number37512-04
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number036-063775
License Number StateIL
# 6
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number03005
License Number StateIA
# 7
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number40617
License Number StateMN
# 8
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number37512-021
License Number StateWI
# 9
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number37512-021
License Number StateWI
# 10
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number40617
License Number StateMN
# 11
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number03005
License Number StateIA
# 12
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-063775
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: