1467653139 NPI number — MRS. MARY PATRICIA WATSON APRN BC

Table of content: MRS. MARY PATRICIA WATSON APRN BC (NPI 1467653139)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467653139 NPI number — MRS. MARY PATRICIA WATSON APRN BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON
Provider First Name:
MARY
Provider Middle Name:
PATRICIA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
APRN BC
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:
1467653139
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:
RR 2 BOX 324X
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAIRMONT
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
26554
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-366-9165
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1201 LOCUST AVENUE
Provider Second Line Business Practice Location Address:
FAIRMONT STATE UNIVERSITY STUDENT HEALTH
Provider Business Practice Location Address City Name:
FAIRMONT
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
26554
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-367-4155
Provider Business Practice Location Address Fax Number:
304-367-4710
Provider Enumeration Date:
05/30/2007

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: 363LF0000X , with the licence number:  26152 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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