Basic Information
| Provider Information | |||||||||
| NPI: | 1487944583 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | CRYSTAL | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1960 | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724031960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8703361485 | ||||||||
| FaxNumber: | 8703361484 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 APACHE, STE. A | ||||||||
| Address2: | |||||||||
| City: | JONESBORO | ||||||||
| State: | AR | ||||||||
| PostalCode: | 724013125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8709358388 | ||||||||
| FaxNumber: | 8709358668 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2011 | ||||||||
| LastUpdateDate: | 05/13/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA-439 | AR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P334 | 01 | AR | MEDICARE PTAN | OTHER |