Provider Demographics
NPI:1265464036
Name:WATSEN, SHARENE E (PA-C)
Entity Type:Individual
Prefix:
First Name:SHARENE
Middle Name:E
Last Name:WATSEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:SHARENE
Other - Middle Name:E
Other - Last Name:GOSSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:190 E BANNOCK ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83712-6241
Mailing Address - Country:US
Mailing Address - Phone:208-381-2222
Mailing Address - Fax:
Practice Address - Street 1:403 SOUTH 11TH ST
Practice Address - Street 2:STE 100
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6906
Practice Address - Country:US
Practice Address - Phone:208-429-0300
Practice Address - Fax:208-429-0305
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA579363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID20000861Medicare PIN