Provider Demographics
NPI:1023596335
Name:WATSON, MICHAEL LOREN
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LOREN
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 1:1110 WIGWAM
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-2377
Mailing Address - Country:US
Mailing Address - Phone:512-925-9945
Mailing Address - Fax:
Practice Address - Street 1:1110 WIGWAM
Practice Address - Street 2:
Practice Address - City:LEANDER
Practice Address - State:TX
Practice Address - Zip Code:78641-2377
Practice Address - Country:US
Practice Address - Phone:512-925-9945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-31
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX157378164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse