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General NPI Number Information
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NPI Number | 1992114730
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Entity Type | Organization
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Legal Business Name | JOHN MICHAEL WAITE, PHYSICIAN ASSISTANT, INC.
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Dates
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Enumeration Date | 08/06/2014
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Last Update Date | 08/06/2014
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Provider Practice Location Address
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Address Line | 3325 17TH ST
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City | SANTA MONICA
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State | CA
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Zip | 90405-5832
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Country | US
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Telephone | 310-968-3123
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Fax |
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Provider Business Mailing Address
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Address Line | 3325 17TH ST
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City | SANTA MONICA
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State | CA
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Zip | 90405-5832
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. JOHN MICHAEL WAITE
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Credential | PA-C
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Telephone | 310-968-3123
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | 56135
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License Number State | CA
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