MEDICARE: TANNER COLE WATERMAN PA-C

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	363A00000X	Physician Assistant	PA9118928	FL

General Provider Information

NPI Number	:	1871233932
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANNER COLE WATERMAN PA-C

Provider Business Mailing Address
First Line	:	PO BOX 117345
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30368-7345
Country	:	US
Telephone Number	:	904-346-3465
Fax Number	:	904-858-6489

Provider Business Practice Location Address
First Line	:	1577 ROBERTS DR STE 225
Second Line	:
City	:	JACKSONVILLE BEACH
State	:	FL
Zip	:	32250-3265
Country	:	US
Telephone Number	:	904-241-1204
Fax Number	:	904-241-7331

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

Provider Enumeration Date	:	03/29/2022
Last Update Date	:	06/06/2026

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Directions to “ TANNER COLE WATERMAN PA-C” Practice Location

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