Provider Demographics
NPI:1265136576
Name:WATTERS, DARREN MICHAEL (ATC, EMT, FF, MA)
Entity type:Individual
Prefix:
First Name:DARREN
Middle Name:MICHAEL
Last Name:WATTERS
Suffix:
Gender:M
Credentials:ATC, EMT, FF, MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5834 GEM CT
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93536-5602
Mailing Address - Country:US
Mailing Address - Phone:661-202-0448
Mailing Address - Fax:
Practice Address - Street 1:3041 W AVENUE K
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93536-5426
Practice Address - Country:US
Practice Address - Phone:661-722-6300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE073489146L00000X
CA20000254732255A2300X
CA174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
No146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer