Basic Information
| Provider Information | |||||||||
| NPI: | 1295742948 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAITE | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | R. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAITE | ||||||||
| OtherFirstName: | GLENN | ||||||||
| OtherMiddleName: | RONALD | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 232 S WHISPERWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837094900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083506450 | ||||||||
| FaxNumber: | 2083506449 | ||||||||
| Practice Location | |||||||||
| Address1: | 232 S WHISPERWOOD WAY | ||||||||
| Address2: | |||||||||
| City: | BOISE | ||||||||
| State: | ID | ||||||||
| PostalCode: | 837094900 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2083506450 | ||||||||
| FaxNumber: | 2083506449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 06/25/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 8577 | NV | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | A38237 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 23679 | CO | N | Allopathic & Osteopathic Physicians | Family Medicine | 2081P0004X | A38237 | CA | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine | 2081P0004X | 23679 | CO | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine | 2081P0004X | 8577 | NV | N | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | Spinal Cord Injury Medicine | 208100000X | M-11148 | ID | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.