Provider Demographics
NPI:1417330341
Name:WATSON, JUSTINE
Entity Type:Individual
Prefix:
First Name:JUSTINE
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 OGLETOWN STANTON RD STE 5A43
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19718-2200
Mailing Address - Country:US
Mailing Address - Phone:302-623-0188
Mailing Address - Fax:302-733-5640
Practice Address - Street 1:6934 AVIATION BLVD STE B
Practice Address - Street 2:
Practice Address - City:GLEN BURNIE
Practice Address - State:MD
Practice Address - Zip Code:21061-2593
Practice Address - Country:US
Practice Address - Phone:443-949-0814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05824363AM0700X
DEC5-0001071363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant