Healthcare Provider Details

I. General information

NPI: 1972958353
Provider Name (Legal Business Name): JOSEPH E WATTERS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 10/26/2020
Certification Date: 10/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3100 E FLETCHER AVE
TAMPA FL
33613-4613
US

IV. Provider business mailing address

12802 TAMPA OAKS BLVD STE 300
TEMPLE TERRACE FL
33637-1903
US

V. Phone/Fax

Practice location:
  • Phone: 256-504-4165
  • Fax:
Mailing address:
  • Phone: 855-687-0618
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA.1143
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9112435
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: