Provider Demographics
NPI:1730953670
Name:WAITS, BROOK PAULETTE (PSS CERTIFICATION)
Entity type:Individual
Prefix:
First Name:BROOK
Middle Name:PAULETTE
Last Name:WAITS
Suffix:
Gender:F
Credentials:PSS CERTIFICATION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:390 W MARINE DR APT 1
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:OR
Mailing Address - Zip Code:97103-6208
Mailing Address - Country:US
Mailing Address - Phone:503-741-7210
Mailing Address - Fax:
Practice Address - Street 1:390 W MARINE DR APT 1
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:OR
Practice Address - Zip Code:97103-6208
Practice Address - Country:US
Practice Address - Phone:503-741-7210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-10
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000110005175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist