Provider Demographics
NPI:1457318560
Name:WATERMAN, STEVEN MARK (PA)
Entity Type:Individual
Prefix:MR
First Name:STEVEN
Middle Name:MARK
Last Name:WATERMAN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
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Mailing Address - Street 1:PO BOX 41239
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-0021
Mailing Address - Country:US
Mailing Address - Phone:512-334-7876
Mailing Address - Fax:512-445-6095
Practice Address - Street 1:1400 GEORGE DIETER DR
Practice Address - Street 2:SUITE 270
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79936-7653
Practice Address - Country:US
Practice Address - Phone:915-849-5114
Practice Address - Fax:915-849-5467
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXPA02680363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX327528101Medicaid
TX324406YKN5Medicare PIN