Provider Demographics
NPI:1760753081
Name:WATERS, CRISTY L (PA-C)
Entity Type:Individual
Prefix:
First Name:CRISTY
Middle Name:L
Last Name:WATERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRISTY
Other - Middle Name:L
Other - Last Name:BARBER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3500 POTOMAC WAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-4974
Mailing Address - Country:US
Mailing Address - Phone:208-522-7666
Mailing Address - Fax:208-524-2821
Practice Address - Street 1:3500 POTOMAC WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-4974
Practice Address - Country:US
Practice Address - Phone:208-522-7666
Practice Address - Fax:208-524-2821
Is Sole Proprietor?:No
Enumeration Date:2012-01-18
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical