Provider Demographics
NPI:1760118566
Name:WATSON, MIRRISHA
Entity Type:Individual
Prefix:
First Name:MIRRISHA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5139 SANDY BANKS RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27616-8427
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:409 WAKE CHAPEL RD
Practice Address - Street 2:
Practice Address - City:FUQUAY VARINA
Practice Address - State:NC
Practice Address - Zip Code:27526-1956
Practice Address - Country:US
Practice Address - Phone:919-514-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-26
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCWATS-VB04G363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily