Provider Demographics
NPI:1376862862
Name:WAITE, GORDON WALLACE JR
Entity Type:Individual
Prefix:MR
First Name:GORDON
Middle Name:WALLACE
Last Name:WAITE
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5953 LANDIS AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-3821
Mailing Address - Country:US
Mailing Address - Phone:916-487-5049
Mailing Address - Fax:916-487-5049
Practice Address - Street 1:5953 LANDIS AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-3821
Practice Address - Country:US
Practice Address - Phone:916-487-5049
Practice Address - Fax:916-487-5049
Is Sole Proprietor?:No
Enumeration Date:2010-05-23
Last Update Date:2010-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA673704163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse