Provider Demographics
NPI:1215094081
Name:WATTERS, AMBER LYNN (PA-C, MMS)
Entity type:Individual
Prefix:MRS
First Name:AMBER
Middle Name:LYNN
Last Name:WATTERS
Suffix:
Gender:F
Credentials:PA-C, MMS
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 64316
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-4316
Mailing Address - Country:US
Mailing Address - Phone:443-506-0707
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-02
Last Update Date:2011-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD189397Y64Medicare PIN