Provider Demographics
NPI:1467450619
Name:WATSON, LARRY G (CRNA)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:G
Last Name:WATSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4100 SUMMERHILL RD
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2732
Mailing Address - Country:US
Mailing Address - Phone:903-735-9802
Mailing Address - Fax:903-735-9806
Practice Address - Street 1:4100 SUMMERHILL RD
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2732
Practice Address - Country:US
Practice Address - Phone:903-735-9802
Practice Address - Fax:903-735-9806
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1065502367500000X
TX229614367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1467450619OtherARKANSAS BLUE CROSS
TX088825703Medicaid
AR120883701Medicaid
TX8089UHOtherTEXAS BLUE CROSS
TX8089UHOtherTEXAS BLUE CROSS
TX088825701Medicaid