Provider Demographics
NPI:1033835863
Name:WATSON, MATTHEW BRADLEY (CRNA)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:BRADLEY
Last Name:WATSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1714 PUCKETT LAKE RD
Mailing Address - Street 2:
Mailing Address - City:WEST MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71292-8180
Mailing Address - Country:US
Mailing Address - Phone:318-614-9471
Mailing Address - Fax:
Practice Address - Street 1:5501 S MCCOLL RD
Practice Address - Street 2:
Practice Address - City:EDINBURG
Practice Address - State:TX
Practice Address - Zip Code:78539-5503
Practice Address - Country:US
Practice Address - Phone:867-795-6362
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-13
Last Update Date:2022-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1096791367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered