Basic Information
| Provider Information | |||||||||
| NPI: | 1245492545 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | AGATHA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 800 MEDICAL CENTER DR STE C | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4062621109 | ||||||||
| FaxNumber: | 9406262113 | ||||||||
| Practice Location | |||||||||
| Address1: | 800 MEDICAL CENTER DR STE C | ||||||||
| Address2: | |||||||||
| City: | DECATUR | ||||||||
| State: | TX | ||||||||
| PostalCode: | 762343844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9406262110 | ||||||||
| FaxNumber: | 9406262113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA05810 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 319647902 | 05 | TX | MEDICAID | 8N0426 | 01 | TX | BCBSTX | OTHER |