Basic Information
| Provider Information | |||||||||
| NPI: | 1528529245 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WASELESKI | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOSEPH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11375 CORTEZ BLVD | ||||||||
| Address2: | STATE ROAD 50 | ||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346135409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525792755 | ||||||||
| FaxNumber: | 3525916317 | ||||||||
| Practice Location | |||||||||
| Address1: | 11375 CORTEZ BLVD. | ||||||||
| Address2: | STATE ROAD 50 | ||||||||
| City: | BROOKSVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 34613 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3525922755 | ||||||||
| FaxNumber: | 3525922753 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/26/2019 | ||||||||
| LastUpdateDate: | 03/26/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.