Provider Demographics
NPI:1093879694
Name:WATT, JOHN WILLIAM (APRN)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:WILLIAM
Last Name:WATT
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95-208 WAIKALANI DR
Mailing Address - Street 2:
Mailing Address - City:MILILANI
Mailing Address - State:HI
Mailing Address - Zip Code:96789-3545
Mailing Address - Country:US
Mailing Address - Phone:808-623-6950
Mailing Address - Fax:808-842-2956
Practice Address - Street 1:400 SAND ISLAND RD
Practice Address - Street 2:USCG MEDICAL CLINIC
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819
Practice Address - Country:US
Practice Address - Phone:808-842-2930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-20
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIAPRN 63363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIAPRN 63OtherSTATE APRN LICENSE
HIRN-27892OtherRN LICENSE
HI20850-4Medicaid