Provider Demographics
NPI:1891253092
Name:WATTS, THOMAS GEORGE (FNP-C)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:GEORGE
Last Name:WATTS
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9223 S HARDING AVE
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-1440
Mailing Address - Country:US
Mailing Address - Phone:708-673-3223
Mailing Address - Fax:
Practice Address - Street 1:4711 GOLF RD STE 1250
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60076-1232
Practice Address - Country:US
Practice Address - Phone:847-235-6103
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041.428148163W00000X
IL209.018870363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse