Provider Demographics
NPI:1538511688
Name:WATERS, ALAN D
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:D
Last Name:WATERS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 OAKHURST AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4660
Mailing Address - Country:US
Mailing Address - Phone:616-453-3359
Mailing Address - Fax:
Practice Address - Street 1:957 BROOKHAVEN CT STE 3&4
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-3890
Practice Address - Country:US
Practice Address - Phone:231-777-1916
Practice Address - Fax:231-773-8904
Is Sole Proprietor?:No
Enumeration Date:2016-07-12
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704231084363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner