Provider Demographics
NPI:1215222708
Name:WALDO, JEREMY JAY (CNP)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:JAY
Last Name:WALDO
Suffix:
Gender:M
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 COUNTY ROAD 11 NW
Mailing Address - Street 2:
Mailing Address - City:PINE ISLAND
Mailing Address - State:MN
Mailing Address - Zip Code:55963-9756
Mailing Address - Country:US
Mailing Address - Phone:507-356-4929
Mailing Address - Fax:
Practice Address - Street 1:111 COUNTY ROAD 11 NW
Practice Address - Street 2:
Practice Address - City:PINE ISLAND
Practice Address - State:MN
Practice Address - Zip Code:55963-9756
Practice Address - Country:US
Practice Address - Phone:507-356-4929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-13
Last Update Date:2011-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1432965363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily