1700112497 NPI number — MISS MEGAN SUZANNE WATERS PA-C

Table of content: MISS MEGAN SUZANNE WATERS PA-C (NPI 1700112497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700112497 NPI number — MISS MEGAN SUZANNE WATERS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
MEGAN
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MARSHALL
Provider Other First Name:
MEGAN
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700112497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7794 FIVE MILE ROAD
Provider Second Line Business Mailing Address:
SUITE 240
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45230
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-231-1575
Provider Business Mailing Address Fax Number:
855-818-3918

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7794 5 MILE RD
Provider Second Line Business Practice Location Address:
SUITE 240
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45230-2368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-231-1575
Provider Business Practice Location Address Fax Number:
855-818-3918
Provider Enumeration Date:
10/30/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  002989 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)