Provider Demographics
NPI:1295003374
Name:WATRY, JENNIFER ROSE (PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:ROSE
Last Name:WATRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9735 N 90TH PL
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-5067
Mailing Address - Country:US
Mailing Address - Phone:480-222-4954
Mailing Address - Fax:602-297-6556
Practice Address - Street 1:9735 N 90TH PL
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258
Practice Address - Country:US
Practice Address - Phone:480-222-4954
Practice Address - Fax:602-297-6556
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2018-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5013363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ102176Medicare PIN