Provider Demographics
NPI:1285628461
Name:WATKINS, MARYJO A (CRNA)
Entity Type:Individual
Prefix:
First Name:MARYJO
Middle Name:A
Last Name:WATKINS
Suffix:
Gender:F
Credentials:CRNA
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 99
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27023-0099
Mailing Address - Country:US
Mailing Address - Phone:731-234-2335
Mailing Address - Fax:
Practice Address - Street 1:155 MEMORIAL DR
Practice Address - Street 2:ANESTHESIA DEPT
Practice Address - City:PINEHURST
Practice Address - State:NC
Practice Address - Zip Code:28374-8710
Practice Address - Country:US
Practice Address - Phone:910-715-1235
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN10681367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3627252Medicaid
00013859OtherNHC CARE ADMINISTRATORS
TN4053056OtherBLUE SHIELD OF TN
278219OtherANTHEM BCBS
TN0100OtherJOHN DEERE
KY74005992Medicaid
KY74005992Medicaid