Provider Demographics
NPI:1619917598
Name:WATKINS, WILLIAM JAMES (NP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JAMES
Last Name:WATKINS
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 1:2669 HIGHWAY D
Mailing Address - Street 2:
Mailing Address - City:ELLINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:63638-7736
Mailing Address - Country:US
Mailing Address - Phone:573-429-9346
Mailing Address - Fax:
Practice Address - Street 1:1000 W 10TH ST
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-2905
Practice Address - Country:US
Practice Address - Phone:573-364-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO137035363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428376602Medicaid
MOP79717Medicare UPIN
MO000081444Medicare ID - Type Unspecified
MO428376602Medicaid