Provider Demographics
NPI:1790979805
Name:WATSON, MICHAEL PATRICK (PA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PATRICK
Last Name:WATSON
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 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-416-6159
Mailing Address - Fax:850-475-4619
Practice Address - Street 1:5149 N 9TH AVE
Practice Address - Street 2:SUITE 246
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32504-8756
Practice Address - Country:US
Practice Address - Phone:850-416-6159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-31
Last Update Date:2013-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107263363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ3677OtherSTATE LICENSE
ALPA-562OtherSTATE LICENSE
ALPA-562OtherSTATE LICENSE
ALK482Medicare PIN