Provider Demographics
NPI:1073950440
Name:WAITE, JASON (DPM)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:WAITE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 110
Mailing Address - Street 2:
Mailing Address - City:CASTLE DALE
Mailing Address - State:UT
Mailing Address - Zip Code:84513-0110
Mailing Address - Country:US
Mailing Address - Phone:516-506-8839
Mailing Address - Fax:
Practice Address - Street 1:1257 PAIUTE CIR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-3202
Practice Address - Country:US
Practice Address - Phone:516-506-8839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-25
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9114085-0501213EP1101X, 213E00000X
CO0000729213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine