Provider Demographics
NPI:1831178953
Name:WAITE, GREGORY LEE (PT, DPT)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
Last Name:WAITE
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:991 ROUTE 19N, SUITE E
Mailing Address - Street 2:
Mailing Address - City:WATERFORD
Mailing Address - State:PA
Mailing Address - Zip Code:16441
Mailing Address - Country:US
Mailing Address - Phone:814-796-3400
Mailing Address - Fax:814-796-8533
Practice Address - Street 1:991 ROUTE 19N, SUITE E
Practice Address - Street 2:
Practice Address - City:WATERFORD
Practice Address - State:PA
Practice Address - Zip Code:16441
Practice Address - Country:US
Practice Address - Phone:814-796-3400
Practice Address - Fax:814-796-8533
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT008555L225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1017340310001Medicaid
PA0018701660001Medicaid
066033VL8Medicare PIN