Provider Demographics
NPI:1255746962
Name:WATSON, JOHN JR (NP-C)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:WATSON
Suffix:JR
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S ELLIOTT ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-6421
Mailing Address - Country:US
Mailing Address - Phone:918-825-3777
Mailing Address - Fax:918-825-3776
Practice Address - Street 1:510 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-6421
Practice Address - Country:US
Practice Address - Phone:918-825-3777
Practice Address - Fax:918-825-3776
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-23
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK99514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily