Provider Demographics
NPI:1386783017
Name:WATERS, LAWRENCE JOSEPH (PA-C)
Entity type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:JOSEPH
Last Name:WATERS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2628 MONROE ST NE
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20018-2918
Mailing Address - Country:US
Mailing Address - Phone:215-300-3492
Mailing Address - Fax:
Practice Address - Street 1:1221 MERCANTILE LN
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20774-5374
Practice Address - Country:US
Practice Address - Phone:301-618-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0003373363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical