Provider Demographics
NPI:1770996365
Name:WATSON, FREDRICK EDWARD (EMT3)
Entity type:Individual
Prefix:
First Name:FREDRICK
Middle Name:EDWARD
Last Name:WATSON
Suffix:
Gender:M
Credentials:EMT3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 528
Mailing Address - Street 2:ATTN: BH EMERGENCY SERVICES
Mailing Address - City:BETHEL
Mailing Address - State:AK
Mailing Address - Zip Code:99559-0528
Mailing Address - Country:US
Mailing Address - Phone:907-543-6100
Mailing Address - Fax:
Practice Address - Street 1:829 CHIEF EDDIE HOFFMAN HWY
Practice Address - Street 2:SUITE 150
Practice Address - City:BETHEL
Practice Address - State:AK
Practice Address - Zip Code:99559-0528
Practice Address - Country:US
Practice Address - Phone:907-543-6100
Practice Address - Fax:907-543-6159
Is Sole Proprietor?:No
Enumeration Date:2014-06-11
Last Update Date:2017-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 171M00000X
AK10035002146M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No146M00000XEmergency Medical Service ProvidersEmergency Medical Technician, Intermediate
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1020986Medicaid