Provider Demographics
NPI:1265899975
Name:WATSON, GARY
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
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 1:11034 N 55TH AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-3934
Mailing Address - Country:US
Mailing Address - Phone:602-510-2989
Mailing Address - Fax:
Practice Address - Street 1:11034 N 55TH AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-3934
Practice Address - Country:US
Practice Address - Phone:602-510-2989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-26
Last Update Date:2016-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-10582225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist