Provider Demographics
NPI:1073625513
Name:WATKINS, ALTA LOUISE (PA)
Entity Type:Individual
Prefix:MS
First Name:ALTA
Middle Name:LOUISE
Last Name:WATKINS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601-4001
Mailing Address - Country:US
Mailing Address - Phone:315-788-2211
Mailing Address - Fax:315-788-0956
Practice Address - Street 1:513 WASHINGTON ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-4001
Practice Address - Country:US
Practice Address - Phone:315-788-2211
Practice Address - Fax:315-788-0956
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006163363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant