Provider Demographics
NPI:1598115388
Name:WAKNITZ, JEFF JOHN
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:JOHN
Last Name:WAKNITZ
Suffix:
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 1:14820 W WETHERSFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85379-5968
Mailing Address - Country:US
Mailing Address - Phone:623-512-8700
Mailing Address - Fax:
Practice Address - Street 1:14820 W WETHERSFIELD RD
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85379-5968
Practice Address - Country:US
Practice Address - Phone:623-512-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-13
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN143951364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health