Provider Demographics
NPI:1801877022
Name:WATTS, BENJAMIN P (MHS, PA-C)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:P
Last Name:WATTS
Suffix:
Gender:M
Credentials:MHS, PA-C
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Mailing Address - Street 1:6300 E LAKE BLVD
Mailing Address - Street 2:STE. 301
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:3615 HOSPITAL ST
Practice Address - Street 2:
Practice Address - City:PASCAGOULA
Practice Address - State:MS
Practice Address - Zip Code:39581-4112
Practice Address - Country:US
Practice Address - Phone:228-762-3664
Practice Address - Fax:228-769-7015
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-07
Last Update Date:2017-03-22
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
ALPA-183363AS0400X
MSPA00164363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL35232Medicare PIN
ALS75619Medicare UPIN