Provider Demographics
NPI:1083655690
Name:WATSON, DENNA R (PA)
Entity Type:Individual
Prefix:
First Name:DENNA
Middle Name:R
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2700 STANLEY GAULT PKWY STE 129
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40223-5176
Mailing Address - Country:US
Mailing Address - Phone:502-253-4917
Mailing Address - Fax:502-489-5751
Practice Address - Street 1:1919 STATE ST STE 364
Practice Address - Street 2:
Practice Address - City:NEW ALBANY
Practice Address - State:IN
Practice Address - Zip Code:47150-6801
Practice Address - Country:US
Practice Address - Phone:812-949-5767
Practice Address - Fax:812-948-4339
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2020-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
KYPA639363AM0700X
IN10000218A363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300005223Medicaid
ININ1189190OtherIN MEDICARE
KY95001467Medicaid
KYR79280Medicare UPIN