Provider Demographics
NPI:1730611468
Name:WATERS, ALISSA C
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:C
Last Name:WATERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3230 UNIVERSITY AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53705-3540
Mailing Address - Country:US
Mailing Address - Phone:608-571-2617
Mailing Address - Fax:
Practice Address - Street 1:3230 UNIVERSITY AVE STE 12
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-3540
Practice Address - Country:US
Practice Address - Phone:608-285-5645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2019-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1566-403246ZA2600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZA2600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherArt, Medical