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General NPI Number Information
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NPI Number | 1902241268
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Entity Type | Individual
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Provider Name | BRETT JOSEPH WAVERLY D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 05/01/2013
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Last Update Date | 09/19/2024
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Provider Practice Location Address
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Address Line | 7840 VINEWOOD LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55369-7185
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Country | US
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Telephone | 763-236-0200
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 43
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City | MINNEAPOLIS
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State | MN
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Zip | 55440-0043
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Country | US
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Telephone | 612-262-1166
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 1085-25
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License Number State | WI
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Taxonomy #2
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | DP201954
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License Number State | OR
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Taxonomy #3
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 016005725
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License Number State | IL
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Taxonomy #4
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | DP201954
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License Number State | OR
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Taxonomy #5
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 016005725
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License Number State | IL
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Taxonomy #6
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 1085-25
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License Number State | WI
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Taxonomy #7
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 1165
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License Number State | MN
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