1740249804 NPI number — PATRICIA ANNE WATERS-DECKER APRN, CNM

Table of content: PATRICIA ANNE WATERS-DECKER APRN, CNM (NPI 1740249804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740249804 NPI number — PATRICIA ANNE WATERS-DECKER APRN, CNM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATERS-DECKER
Provider First Name:
PATRICIA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN, CNM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATERS
Provider Other First Name:
PATRICIA
Provider Other Middle Name:
ANNE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
APRN, CNM
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1740249804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9260 W. SUNSET RD.
Provider Second Line Business Mailing Address:
STE. 200
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89148-4903
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-255-3547
Provider Business Mailing Address Fax Number:
702-921-2419

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10105 BANBURRY CROSS
Provider Second Line Business Practice Location Address:
STE. 460
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89144
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-255-3547
Provider Business Practice Location Address Fax Number:
702-255-3549
Provider Enumeration Date:
03/18/2006

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: 367A00000X , with the licence number:  APN 00446 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 002402048 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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