Provider Demographics
NPI:1689767675
Name:WATSON, BRENDA G (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:BRENDA
Middle Name:G
Last Name:WATSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TRILLIUM WAY STE 205
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40701-8445
Mailing Address - Country:US
Mailing Address - Phone:606-523-2140
Mailing Address - Fax:606-523-2547
Practice Address - Street 1:5000 KY ROUTE 321
Practice Address - Street 2:
Practice Address - City:PRESTONSBURG
Practice Address - State:KY
Practice Address - Zip Code:41653-9113
Practice Address - Country:US
Practice Address - Phone:606-886-8511
Practice Address - Fax:606-523-2547
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2193A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000325815OtherANTHEM
KY000000325815OtherANTHEM
KYS58404Medicare UPIN
KYP00103412Medicare ID - Type UnspecifiedRRMC