Basic Information
| Provider Information | |||||||||
| NPI: | 1952596553 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATTS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | GEDDES | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 460 WILSON AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403831947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8598790111 | ||||||||
| FaxNumber: | 8598790363 | ||||||||
| Practice Location | |||||||||
| Address1: | 460 WILSON AVE | ||||||||
| Address2: | FIRST FLOOR | ||||||||
| City: | VERSAILLES | ||||||||
| State: | KY | ||||||||
| PostalCode: | 403831947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8595374082 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2007 | ||||||||
| LastUpdateDate: | 06/09/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA1056 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 7100049280 | 05 | KY | MEDICAID |