Basic Information
| Provider Information | |||||||||
| NPI: | 1508097015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | BRYAN | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 999 EXECUTIVE PARK BLVD | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376604632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232243250 | ||||||||
| FaxNumber: | 4232243258 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 CLOVERLEAF SQ | ||||||||
| Address2: | #1 | ||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242192760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765236715 | ||||||||
| FaxNumber: | 2765236719 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2009 | ||||||||
| LastUpdateDate: | 09/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0116021762 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207P00000X | 0102202658 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207R00000X | 03406 | KY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0102202658 | VA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1522495 | 05 | TN | MEDICAID | 1508097015 | 05 | VA | MEDICAID | 7100137290 | 05 | KY | MEDICAID | 7617286 | 05 | NC | MEDICAID |