Provider Demographics
NPI:1669805305
Name:WATSON, KELLY JANE-BALDWIN (PA-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:JANE-BALDWIN
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:JANE
Other - Last Name:BALDWIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:700 S TUSTIN ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92866-3425
Mailing Address - Country:US
Mailing Address - Phone:714-922-4100
Mailing Address - Fax:714-633-1784
Practice Address - Street 1:700 S TUSTIN ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-3425
Practice Address - Country:US
Practice Address - Phone:714-922-4100
Practice Address - Fax:714-633-1784
Is Sole Proprietor?:No
Enumeration Date:2013-08-16
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23137363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical