Basic Information
| Provider Information | |||||||||
| NPI: | 1831161702 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | ANN | ||||||||
| MiddleName: | KATHERINE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PAC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 214 DOCTORS ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28675 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363725606 | ||||||||
| FaxNumber: | 3363726211 | ||||||||
| Practice Location | |||||||||
| Address1: | 214 DOCTORS ST | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286759247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3363725606 | ||||||||
| FaxNumber: | 3363726211 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/06/2006 | ||||||||
| LastUpdateDate: | 04/30/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 100897 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | P00103094 | 01 | NC | RAILROAD MEDICARE | OTHER | P00106094 | 01 | UNITED HEALTHCARE | OTHER |