Provider Demographics
NPI:1003085457
Name:WATERS, TAYLOR A (PT,DPT)
Entity Type:Individual
Prefix:DR
First Name:TAYLOR
Middle Name:A
Last Name:WATERS
Suffix:
Gender:F
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 SR 311 TRLR 21
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:NM
Mailing Address - Zip Code:88101-1294
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE
Practice Address - Street 2:BLDG 1408
Practice Address - City:CANNON AFB
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:540-692-4484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-29
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305205357225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA017052P30Medicare PIN