Provider Demographics
NPI:1609499391
Name:WATSON, SHANNON JEWEL (PA)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:JEWEL
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5124 U ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1644
Mailing Address - Country:US
Mailing Address - Phone:530-651-4572
Mailing Address - Fax:
Practice Address - Street 1:2570 48TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1541
Practice Address - Country:US
Practice Address - Phone:916-734-2145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-28
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CA58748363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant