1285628461 NPI number — MARYJO A WATKINS CRNA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285628461 NPI number — MARYJO A WATKINS CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATKINS
Provider First Name:
MARYJO
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CRNA
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:
1285628461
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 99
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LEWISVILLE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27023-0099
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
731-234-2335
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
155 MEMORIAL DR
Provider Second Line Business Practice Location Address:
ANESTHESIA DEPT
Provider Business Practice Location Address City Name:
PINEHURST
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28374-8710
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-715-1235
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/02/2005

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: 367500000X , with the licence number:  10681 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3627252 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00013859 . This is a "NHC CARE ADMINISTRATORS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4053056 . This is a "BLUE SHIELD OF TN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 278219 . This is a "ANTHEM BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: TN0100 . This is a "JOHN DEERE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 74005992 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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