Basic Information
| Provider Information | |||||||||
| NPI: | 1477104230 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 24607 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681240607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029555400 | ||||||||
| FaxNumber: | 4029553674 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 N 175TH ST STE 1000 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681183581 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4029555437 | ||||||||
| FaxNumber: | 4029557310 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2019 | ||||||||
| LastUpdateDate: | 01/22/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | 112802 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.