Provider Demographics
NPI:1053685354
Name:WATERS, KRISTINE ANDERSON (PA-C)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:ANDERSON
Last Name:WATERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14164 MAHOGANY AVE
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32258-5513
Mailing Address - Country:US
Mailing Address - Phone:904-654-9892
Mailing Address - Fax:
Practice Address - Street 1:105 SOUTHPARK BLVD STE A103
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-4162
Practice Address - Country:US
Practice Address - Phone:904-342-7765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9106439363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant