Provider Demographics
NPI:1093713919
Name:WATT, LAURIE (PA)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:
Last Name:WATT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:RAE
Other - Last Name:STEWART
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:404 E ELM AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-2657
Mailing Address - Country:US
Mailing Address - Phone:734-240-0689
Mailing Address - Fax:
Practice Address - Street 1:16001 W 9 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4818
Practice Address - Country:US
Practice Address - Phone:248-849-3856
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001765363AM0700X
MI5601003719363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Not Answered363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH76771Medicare ID - Type UnspecifiedMEDICARE
OH50507Medicare UPIN