Provider Demographics
NPI:1649372145
Name:WATERS, TRAVIS PAUL (PA-C)
Entity type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:PAUL
Last Name:WATERS
Suffix:
Gender:M
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 1:35 TANNER PKWY
Mailing Address - Street 2:
Mailing Address - City:CANON CITY
Mailing Address - State:CO
Mailing Address - Zip Code:81212-9418
Mailing Address - Country:US
Mailing Address - Phone:719-276-0967
Mailing Address - Fax:
Practice Address - Street 1:559 VINCENT ST
Practice Address - Street 2:STE. 102
Practice Address - City:PETERSON AFB
Practice Address - State:CO
Practice Address - Zip Code:80914-1541
Practice Address - Country:US
Practice Address - Phone:719-556-1131
Practice Address - Fax:719-556-1129
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1722363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant