Basic Information
| Provider Information | |||||||||
| NPI: | 1407464118 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTERS | ||||||||
| FirstName: | GEOFFREY | ||||||||
| MiddleName: | B | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4143892233 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1220 DEWEY AVE | ||||||||
| Address2: | |||||||||
| City: | WAUWATOSA | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532132504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4144546753 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2020 | ||||||||
| LastUpdateDate: | 11/23/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 10388-33 | WI | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 10388-33 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.