Provider Demographics
NPI:1114064789
Name:WAITE, JAY RUSSELL (IDC)
Entity Type:Individual
Prefix:MR
First Name:JAY
Middle Name:RUSSELL
Last Name:WAITE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:733 ORCHARD DR APT A
Mailing Address - Street 2:
Mailing Address - City:FALLON
Mailing Address - State:NV
Mailing Address - Zip Code:89406-6158
Mailing Address - Country:US
Mailing Address - Phone:775-426-3130
Mailing Address - Fax:775-426-3133
Practice Address - Street 1:4755 PASTURE RD
Practice Address - Street 2:
Practice Address - City:FALLON
Practice Address - State:NV
Practice Address - Zip Code:89496-5000
Practice Address - Country:US
Practice Address - Phone:775-426-3130
Practice Address - Fax:775-426-3133
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman