Provider Demographics
NPI:1962473462
Name:WATSON, MICHAEL GARY (APRN, FNP-BC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:GARY
Last Name:WATSON
Suffix:
Gender:M
Credentials:APRN, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 PINE ST
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501-5100
Mailing Address - Country:US
Mailing Address - Phone:903-798-8880
Mailing Address - Fax:903-798-8885
Practice Address - Street 1:800 EAST DAWSON STREET
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701
Practice Address - Country:US
Practice Address - Phone:903-593-8441
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX607206363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
S93831Medicare UPIN
83N459Medicare ID - Type Unspecified