Healthcare Provider Details

I. General information

NPI: 1326010174
Provider Name (Legal Business Name): JEFFREY A WATERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2006
Last Update Date: 08/03/2021
Certification Date: 08/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E FONTANERO ST STE 100
COLORADO SPRINGS CO
80907-7535
US

IV. Provider business mailing address

2695 ROCKY MOUNTAIN AVE STE 150
LOVELAND CO
80538-9071
US

V. Phone/Fax

Practice location:
  • Phone: 719-365-7420
  • Fax:
Mailing address:
  • Phone: 719-630-6440
  • Fax: 719-228-6609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number909
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: