Provider Demographics
NPI:1588199624
Name:WATSON, PETER MALCOLM (NP)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:MALCOLM
Last Name:WATSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10401 ONONDAGA RD
Mailing Address - Street 2:
Mailing Address - City:ONONDAGA
Mailing Address - State:MI
Mailing Address - Zip Code:49264-9630
Mailing Address - Country:US
Mailing Address - Phone:517-745-0923
Mailing Address - Fax:
Practice Address - Street 1:10401 ONONDAGA RD
Practice Address - Street 2:
Practice Address - City:ONONDAGA
Practice Address - State:MI
Practice Address - Zip Code:49264-9630
Practice Address - Country:US
Practice Address - Phone:517-745-0923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201699363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health