Provider Demographics
NPI:1619568730
Name:WATSON, DEREK (RN)
Entity type:Individual
Prefix:
First Name:DEREK
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2510 S BURRELL ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53207-1524
Mailing Address - Country:US
Mailing Address - Phone:317-695-6458
Mailing Address - Fax:
Practice Address - Street 1:1610 MILLER PARK WAY
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53214-3604
Practice Address - Country:US
Practice Address - Phone:414-672-3801
Practice Address - Fax:414-672-6026
Is Sole Proprietor?:No
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI193697-30163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)