Healthcare Provider Details

I. General information

NPI: 1619962149
Provider Name (Legal Business Name): LISA JAYNE WATTERS D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2005
Last Update Date: 10/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3275 LEECHBURG RD SUITE 2
LOWER BURRELL PA
15068-2858
US

IV. Provider business mailing address

3275 LEECHBURG RD SUITE 2
LOWER BURRELL PA
15068-2858
US

V. Phone/Fax

Practice location:
  • Phone: 724-339-3500
  • Fax: 724-339-8331
Mailing address:
  • Phone: 724-339-3500
  • Fax: 724-339-8331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberSC003169L
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberSC003169L
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code213ER0200X
TaxonomyRadiology Podiatrist
License NumberSC003169L
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberSC003169L
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberSC003169L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: