Provider Demographics
NPI:1013916378
Name:WATSON, MARILYN HOPSON (APRN)
Entity Type:Individual
Prefix:MRS
First Name:MARILYN
Middle Name:HOPSON
Last Name:WATSON
Suffix:
Gender:F
Credentials:APRN
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 4610
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70606-4610
Mailing Address - Country:US
Mailing Address - Phone:337-312-1000
Mailing Address - Fax:337-527-8963
Practice Address - Street 1:1200 STELLY LN
Practice Address - Street 2:
Practice Address - City:SULPHUR
Practice Address - State:LA
Practice Address - Zip Code:70663-5134
Practice Address - Country:US
Practice Address - Phone:337-312-1000
Practice Address - Fax:337-527-8963
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN054586-AP03069363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1547352Medicaid
P15685Medicare UPIN
4B598Medicare ID - Type Unspecified