Provider Demographics
NPI:1306964994
Name:WAITES, KATIE DIANA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:KATIE
Middle Name:DIANA
Last Name:WAITES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:KATIE
Other - Middle Name:DIANA
Other - Last Name:MALLABURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:EMT-P, PA
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 E PARKCENTER BLVD
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83706-6528
Practice Address - Country:US
Practice Address - Phone:208-381-4210
Practice Address - Fax:208-381-2045
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-1501363A00000X, 363A00000X
OR363AM0700X
ID00048770602376K00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No376K00000XNursing Service Related ProvidersNurse's Aide
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program