Basic Information
| Provider Information | |||||||||
| NPI: | 1033889381 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATERS | ||||||||
| FirstName: | KYLE | ||||||||
| MiddleName: | DOMINIC | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1705 | ||||||||
| Address2: | |||||||||
| City: | AUGUSTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 309031705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7068546008 | ||||||||
| FaxNumber: | 7067747230 | ||||||||
| Practice Location | |||||||||
| Address1: | 925 BRANCH CT STE 201 | ||||||||
| Address2: | |||||||||
| City: | GROVETOWN | ||||||||
| State: | GA | ||||||||
| PostalCode: | 308133325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7063963570 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/17/2021 | ||||||||
| LastUpdateDate: | 11/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.