Provider Demographics
NPI:1073554150
Name:WATSON, WALLACE CARLISLE JR (PA)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:CARLISLE
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2211 W STATE ST
Mailing Address - Street 2:SUITE 121
Mailing Address - City:OLEAN
Mailing Address - State:NY
Mailing Address - Zip Code:14760-1951
Mailing Address - Country:US
Mailing Address - Phone:716-372-2708
Mailing Address - Fax:716-372-8682
Practice Address - Street 1:21 E MAIN ST
Practice Address - Street 2:
Practice Address - City:CUBA
Practice Address - State:NY
Practice Address - Zip Code:14727-1205
Practice Address - Country:US
Practice Address - Phone:585-968-4357
Practice Address - Fax:585-968-4356
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0012551208D00000X
NY001255363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0490352OtherIHA
00010257702OtherUNIVERA
407113852OtherRAILROAD MEDICARE
NY000508499002OtherBCWNY
2598491OtherGHI
NY01531593Medicaid