MEDICARE: NICOLE A WATERS

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	390200000X	Student in an Organized Health Care Education/Training Program
2	363A00000X	Physician Assistant	PA9116808	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1598406464
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE A WATERS

Provider Business Mailing Address
First Line	:	3180 MATHIESON DR NE UNIT 706
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-1868
Country	:	US
Telephone Number	:	949-355-5017
Fax Number	:

Provider Business Practice Location Address
First Line	:	3180 MATHIESON DR NE UNIT 706
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30305-1868
Country	:	US
Telephone Number	:	949-355-5017
Fax Number	:

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

Provider Enumeration Date	:	04/05/2022
Last Update Date	:	05/11/2023

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Directions to “ NICOLE A WATERS ” Practice Location

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