Provider Demographics
NPI:1245772128
Name:WATTS, WALLACE JR (NP-C)
Entity Type:Individual
Prefix:MR
First Name:WALLACE
Middle Name:
Last Name:WATTS
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 202479
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-2479
Mailing Address - Country:US
Mailing Address - Phone:915-790-5700
Mailing Address - Fax:
Practice Address - Street 1:101 POTASIO STREET
Practice Address - Street 2:
Practice Address - City:FABENS
Practice Address - State:TX
Practice Address - Zip Code:79838
Practice Address - Country:US
Practice Address - Phone:915-790-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-09
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP132310363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily