Provider Demographics
NPI:1154705051
Name:WATERS, TIMOTHY LEE JR (ARNP)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:LEE
Last Name:WATERS
Suffix:JR
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2147
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33902-2147
Mailing Address - Country:US
Mailing Address - Phone:239-985-1925
Mailing Address - Fax:239-468-7929
Practice Address - Street 1:16420 HEALTHPARK COMMONS DR
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-9621
Practice Address - Country:US
Practice Address - Phone:239-985-1925
Practice Address - Fax:239-321-6044
Is Sole Proprietor?:No
Enumeration Date:2015-07-10
Last Update Date:2024-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9325102363L00000X
FLARNP 9325102363LA2100X
FLAPRN9325102363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL398643OtherAVMED
FLY0SY4OtherBCBS
FL1254561OtherWELLCARE
FL016793000Medicaid
FLP1036301OtherFREEDOM
FLP973771OtherOPTIMUM
FL7061863OtherCIGNA
FL4857567OtherAETNA
FLP01652219OtherRR MEDICARE
FLY0SY4OtherBCBS