Basic Information
Provider Information | |||||||||
NPI: | 1679869614 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WATKINS | ||||||||
FirstName: | JOHN | ||||||||
MiddleName: | RYAN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2100 STANTONSBURG RD | ||||||||
Address2: |   | ||||||||
City: | GREENVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 278342818 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2527444184 | ||||||||
FaxNumber: | 2527444125 | ||||||||
Practice Location | |||||||||
Address1: | 777 N PALISADES DR | ||||||||
Address2: |   | ||||||||
City: | OREM | ||||||||
State: | UT | ||||||||
PostalCode: | 840974341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8012229200 | ||||||||
FaxNumber: | 3852030079 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/28/2011 | ||||||||
LastUpdateDate: | 05/28/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 01/22/2020 | ||||||||
NPIReactivationDate: | 05/28/2020 | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/28/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 208D00000X | 11573862-1205 | UT | Y |   | Allopathic & Osteopathic Physicians | General Practice |   |
No ID Information.