Provider Demographics
NPI:1033581590
Name:WATERMAN, MARY C (NP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4204 GARDENDALE ST
Mailing Address - Street 2:STE 312
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3132
Mailing Address - Country:US
Mailing Address - Phone:210-293-6006
Mailing Address - Fax:210-614-1722
Practice Address - Street 1:4204 GARDENDALE ST
Practice Address - Street 2:STE 312
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3132
Practice Address - Country:US
Practice Address - Phone:210-293-6006
Practice Address - Fax:210-614-1722
Is Sole Proprietor?:No
Enumeration Date:2015-10-23
Last Update Date:2015-10-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXAP129445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily