Provider Demographics
NPI:1083682405
Name:WAAS, DALE A (PA)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:A
Last Name:WAAS
Suffix:
Gender:M
Credentials:PA
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 735044
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5044
Mailing Address - Country:US
Mailing Address - Phone:414-649-3240
Mailing Address - Fax:
Practice Address - Street 1:2801 W KK RIVER PKWY
Practice Address - Street 2:SUITE 330
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215-3669
Practice Address - Country:US
Practice Address - Phone:414-649-3240
Practice Address - Fax:414-649-3244
Is Sole Proprietor?:No
Enumeration Date:2006-03-10
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI623-023363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42933300Medicaid
WI73445-0011Medicare ID - Type Unspecified
WIR97697Medicare UPIN