Provider Demographics
NPI:1821180431
Name:WAITEK, MARC E (PA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:E
Last Name:WAITEK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:621 S ILLINOIS AVE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:MASON CITY
Mailing Address - State:IA
Mailing Address - Zip Code:50401-5489
Mailing Address - Country:US
Mailing Address - Phone:641-494-3041
Mailing Address - Fax:641-494-3059
Practice Address - Street 1:620 N 8TH ST
Practice Address - Street 2:
Practice Address - City:OSAGE
Practice Address - State:IA
Practice Address - Zip Code:50461-1456
Practice Address - Country:US
Practice Address - Phone:641-732-6100
Practice Address - Fax:641-732-6108
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA000653363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA3063842Medicaid
IA48713OtherWELLMARK
IAS70453Medicare UPIN
IA3063842Medicaid