Basic Information
| Provider Information | |||||||||
| NPI: | 1851394530 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WAITE | ||||||||
| FirstName: | BRUCE | ||||||||
| MiddleName: | KEVIN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 404 W. FOUNTAIN ST | ||||||||
| Address2: | |||||||||
| City: | ALBERT LEA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560072437 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073732384 | ||||||||
| FaxNumber: | 5076682975 | ||||||||
| Practice Location | |||||||||
| Address1: | 1000 FIRST DR NW | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | MN | ||||||||
| PostalCode: | 559122941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5074337351 | ||||||||
| FaxNumber: | 5076682975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207V00000X | DO1972 | ME | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | DO17052 | OR | N | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 207V00000X | 62771 | MN | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 025226 | 05 | OR | MEDICAID |