Provider Demographics
NPI:1679772388
Name:WATTS, WILLIE MACK (PA)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:MACK
Last Name:WATTS
Suffix:
Gender:M
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:PO BOX 73
Mailing Address - Street 2:
Mailing Address - City:PORT ROYAL
Mailing Address - State:SC
Mailing Address - Zip Code:29935-0073
Mailing Address - Country:US
Mailing Address - Phone:256-393-9663
Mailing Address - Fax:
Practice Address - Street 1:4292 GRAY HWY
Practice Address - Street 2:
Practice Address - City:GRAY
Practice Address - State:GA
Practice Address - Zip Code:31032-5900
Practice Address - Country:US
Practice Address - Phone:478-986-2500
Practice Address - Fax:478-864-1288
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPA-184363AM0700X
GA10853363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009911802Medicaid
AL510I970017Medicare PIN