Provider Demographics
NPI:1720186893
Name:WATSON, TANYA (NP)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:420 DELAWARE STREET SE
Mailing Address - Street 2:MMC 292 - UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-5411
Mailing Address - Fax:
Practice Address - Street 1:424 HARVARD STREET SE
Practice Address - Street 2:FIRST FLOOR, SUITE M100 - MASONIC CANCER CENTER
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 137091-7363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1033396OtherPREFERREDONE
MN495A6WAOtherBLUE CROSS BLUE SHIELD MN
MN04-05250OtherUCARE
MN1787201OtherARAZ
MT4301310Medicaid
MNHP40589OtherHEALTHPARTNERS
MN04-05250OtherMEDICA - CHOICE
MN787633500Medicaid
MNP00030527Medicare ID - Type UnspecifiedRAILROAD