Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QG0300X | Family Doctor - Geriatric Medicine | 0S003179L | PA |
NPI | 1356302715 |
---|---|
Provider Name | Dr. Patrick Timothy Waters |
First Address | Miami Gardens, FL 33169-5710 |
Second Address | Philadelphia, PA 19132-2664 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/03/2006 |
Last Update Date | 17/03/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0058143000 | KEYSTONE AND BLUE INDIV # (01) | PA |
85987 | AETNA HMO ONLY (01) | PA |
B40730 | (02) | PA |