Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 225100000X | Physical Therapist | 16820 | CA |
N | 2251X0800X | Physical Therapist - Orthopedic | 16820 | CA |
NPI | 1063496289 |
---|---|
Provider Name | John Robert Waite |
First Address | Murrieta, CA 92562-4458 |
Second Address | Murrieta, CA 92562-4904 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/12/2005 |
Last Update Date | 24/12/2018 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
P01284430 | RR MEDICARE (01) | CA |