Provider Demographics
NPI:1023113545
Name:WATTS, RICHARD GARY (CRNA)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GARY
Last Name:WATTS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 E 1600 S
Mailing Address - Street 2:
Mailing Address - City:MAPLETON
Mailing Address - State:UT
Mailing Address - Zip Code:84664-5202
Mailing Address - Country:US
Mailing Address - Phone:801-491-6315
Mailing Address - Fax:
Practice Address - Street 1:151 E 1600 S
Practice Address - Street 2:
Practice Address - City:MAPLETON
Practice Address - State:UT
Practice Address - Zip Code:84664-5202
Practice Address - Country:US
Practice Address - Phone:801-491-6315
Practice Address - Fax:801-465-7122
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2024-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVCRNA000370367500000X
IDRNA-846A367500000X
UT308580-4406367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2246747Medicaid
UTD4599Medicaid
ID1023113545Medicaid
UT005717508Medicare ID - Type Unspecified