Basic Information
| Provider Information | |||||||||
| NPI: | 1790264604 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | DAKOTA | ||||||||
| MiddleName: | RYAN | ||||||||
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| Credential: | PT, DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6397 LEE HWY STE 300 | ||||||||
| Address2: | |||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212564 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 W 92 HWY STE H | ||||||||
| Address2: | |||||||||
| City: | KEARNEY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640607591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8169030775 | ||||||||
| FaxNumber: | 8169030776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2018 | ||||||||
| LastUpdateDate: | 08/10/2018 | ||||||||
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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 | 225100000X | 2018028526 | MO | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.