Basic Information
| Provider Information | |||||||||
| NPI: | 1457406035 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | LORRAINE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 N MARTEL AVE | ||||||||
| Address2: | |||||||||
| City: | WEST HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900466611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234365019 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4940 VAN NUYS BLVD STE 200 | ||||||||
| Address2: | |||||||||
| City: | SHERMAN OAKS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914031741 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8183802626 | ||||||||
| FaxNumber: | 8183802620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 06/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 004571 | NY | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | PA19857 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 02166498 | 05 | NY | MEDICAID |