1649372145 NPI number — MR. TRAVIS PAUL WATERS PA-C

Table of content: MR. TRAVIS PAUL WATERS PA-C (NPI 1649372145)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649372145 NPI number — MR. TRAVIS PAUL WATERS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS
Provider First Name:
TRAVIS
Provider Middle Name:
PAUL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1649372145
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 TANNER PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CANON CITY
Provider Business Mailing Address State Name:
CO
Provider Business Mailing Address Postal Code:
81212-9418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
719-276-0967
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
559 VINCENT ST
Provider Second Line Business Practice Location Address:
STE. 102
Provider Business Practice Location Address City Name:
PETERSON AFB
Provider Business Practice Location Address State Name:
CO
Provider Business Practice Location Address Postal Code:
80914-1541
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
719-556-1131
Provider Business Practice Location Address Fax Number:
719-556-1129
Provider Enumeration Date:
09/04/2006

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:  1722 , registered in the state of CO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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