Provider Demographics
NPI:1114402153
Name:WATSON, BROOKE ELIZABETH (PA-C)
Entity Type:Individual
Prefix:MS
First Name:BROOKE
Middle Name:ELIZABETH
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 530062
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-0062
Mailing Address - Country:US
Mailing Address - Phone:843-695-6071
Mailing Address - Fax:843-569-5881
Practice Address - Street 1:5500 FRONT ST STE 260
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-8140
Practice Address - Country:US
Practice Address - Phone:843-576-0700
Practice Address - Fax:843-576-0701
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2022-06-15
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC3386PAMedicaid