Basic Information
| Provider Information | |||||||||
| NPI: | 1891070694 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAITE | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 KILLEBREW DR | ||||||||
| Address2: | STE 308 | ||||||||
| City: | BLOOMINGTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554251886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6519997022 | ||||||||
| FaxNumber: | 6519996970 | ||||||||
| Practice Location | |||||||||
| Address1: | 9825 HOSPITAL DR STE 205 | ||||||||
| Address2: | |||||||||
| City: | MAPLE GROVE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553694480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7635877000 | ||||||||
| FaxNumber: | 7635877015 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2011 | ||||||||
| LastUpdateDate: | 09/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 363AM0700X | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 085.004163 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 13027 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.