MEDICARE: MR. THOMAS W WATERS PHYSICIAN ASSISTANT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant

General Provider Information

NPI Number	:	1225014210
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. THOMAS W WATERS PHYSICIAN ASSISTANT

Provider Business Mailing Address
First Line	:	5911 LAUREL RIDGE DR
Second Line	:
City	:	NEWBURGH
State	:	IN
Zip	:	47630-8067
Country	:	US
Telephone Number	:	812-490-7794
Fax Number	:

Provider Business Practice Location Address
First Line	:	5911 LAUREL RIDGE DR
Second Line	:
City	:	NEWBURGH
State	:	IN
Zip	:	47630-8067
Country	:	US
Telephone Number	:	812-490-7794
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	03/29/2010

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