MEDICARE: SHANNON URSULA WATERMAN MD

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	208600000X	Surgery Physician	025209MD00041909	WA
2	208D00000X	General Practice Physician	MD00041919	WA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00707652	OTHER		MEDICARE RAILROAD

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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649279860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON URSULA WATERMAN MD

Provider Business Mailing Address
First Line	:	101 E 26TH STREET
Second Line	:
City	:	TACOMA
State	:	WA
Zip	:	98421
Country	:	US
Telephone Number	:	253-722-1540
Fax Number	:	253-722-1546

Provider Business Practice Location Address
First Line	:	11225 PACIFIC AVENUE
Second Line	:	PARKLAND CLINIC COMMUNITY HEALTHCARE
City	:	TACOMA
State	:	WA
Zip	:	98444
Country	:	US
Telephone Number	:	253-536-2020
Fax Number	:	253-536-5327

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

Provider Enumeration Date	:	07/19/2005
Last Update Date	:	08/05/2009

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