Provider Demographics
NPI:1023748217
Name:WATSON, TYREA ANN
Entity type:Individual
Prefix:
First Name:TYREA
Middle Name:ANN
Last Name:WATSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1222 WHITEHALL DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46615-3755
Mailing Address - Country:US
Mailing Address - Phone:574-386-1931
Mailing Address - Fax:
Practice Address - Street 1:16260 S RANCHO SAHUARITA BLVD
Practice Address - Street 2:
Practice Address - City:SAHUARITA
Practice Address - State:AZ
Practice Address - Zip Code:85629-0047
Practice Address - Country:US
Practice Address - Phone:520-416-7100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
196949246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical AssistantGroup - Multi-Specialty