Provider Demographics
NPI:1780795658
Name:WATZ, TAMMY
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:
Last Name:WATZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 PROGRESS PKWY
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:MO
Mailing Address - Zip Code:63080-2359
Mailing Address - Country:US
Mailing Address - Phone:573-468-3555
Mailing Address - Fax:
Practice Address - Street 1:101 PROGRESS PKWY
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:MO
Practice Address - Zip Code:63080-2359
Practice Address - Country:US
Practice Address - Phone:573-468-3555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MORN089912363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP01135474OtherRAILROAD MEDICARE
MO423846807Medicaid
MO423846807Medicaid
MO152810061Medicare PIN
S71496Medicare UPIN
814292943Medicare Oscar/Certification