1083629703 NPI number — PATRICIA I WATHEN MD

Table of content: PATRICIA I WATHEN MD (NPI 1083629703)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083629703 NPI number — PATRICIA I WATHEN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATHEN
Provider First Name:
PATRICIA
Provider Middle Name:
I
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1083629703
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7703 FLOYD CURL DR
Provider Second Line Business Mailing Address:
MC7977
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78229-3901
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-257-1400
Provider Business Mailing Address Fax Number:
210-257-1428

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
7703 FLOYD CURL DR
Provider Second Line Business Practice Location Address:
MC7977
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78229-3901
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-257-1400
Provider Business Practice Location Address Fax Number:
210-257-1428
Provider Enumeration Date:
07/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  J2839 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110071012 . This is a "MEDICARE RR" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 045969501 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".