Provider Demographics
NPI:1306939095
Name:WATERS, AMY ELIZABETH (PA-C)
Entity type:Individual
Prefix:MRS
First Name:AMY
Middle Name:ELIZABETH
Last Name:WATERS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:WATERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:6410 ROCKLEDGE DR
Mailing Address - Street 2:SUITE 201
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20817-1809
Mailing Address - Country:US
Mailing Address - Phone:301-530-8300
Mailing Address - Fax:
Practice Address - Street 1:6410 ROCKLEDGE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20817-1809
Practice Address - Country:US
Practice Address - Phone:301-530-8300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2017-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003046363AM0700X, 363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD020216P80Medicare UPIN