Provider Demographics
NPI:1992036289
Name:WATSON, CODY ALAN
Entity Type:Individual
Prefix:MR
First Name:CODY
Middle Name:ALAN
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1841 MADORA AVE
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:WY
Mailing Address - Zip Code:82633-3057
Mailing Address - Country:US
Mailing Address - Phone:307-358-2846
Mailing Address - Fax:307-358-5329
Practice Address - Street 1:1841 MADORA AVE
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:WY
Practice Address - Zip Code:82633-3057
Practice Address - Country:US
Practice Address - Phone:307-358-2846
Practice Address - Fax:307-358-5329
Is Sole Proprietor?:No
Enumeration Date:2010-01-26
Last Update Date:2010-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker