Provider Demographics
NPI:1245492545
Name:WATSON, AGATHA RAE (PA)
Entity type:Individual
Prefix:
First Name:AGATHA
Middle Name:RAE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 MEDICAL CENTER DR STE C
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:TX
Mailing Address - Zip Code:76234-3844
Mailing Address - Country:US
Mailing Address - Phone:406-262-1109
Mailing Address - Fax:940-626-2113
Practice Address - Street 1:800 MEDICAL CENTER DR STE C
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:TX
Practice Address - Zip Code:76234-3844
Practice Address - Country:US
Practice Address - Phone:940-626-2110
Practice Address - Fax:940-626-2113
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05810363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX319647902Medicaid
TX8N0426OtherBCBSTX