Provider Demographics
NPI:1407574056
Name:WATSON, MICHAEL D (PA-C)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:D
Last Name:WATSON
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 KITE CIR NE
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-3805
Mailing Address - Country:US
Mailing Address - Phone:907-885-7779
Mailing Address - Fax:
Practice Address - Street 1:113 KITE CIR NE
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-3805
Practice Address - Country:US
Practice Address - Phone:907-885-7779
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-19
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13810363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0010-13830OtherMEDICAL LICENSE