Provider Demographics
NPI:1932789393
Name:WATSON, MICHELLE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WATSON
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 1:114 FOUGERON ST
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14211-1318
Mailing Address - Country:US
Mailing Address - Phone:716-931-5559
Mailing Address - Fax:716-221-8292
Practice Address - Street 1:114 FOUGERON ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14211-1318
Practice Address - Country:US
Practice Address - Phone:716-931-5559
Practice Address - Fax:716-221-8292
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-10
Last Update Date:2021-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY801166729343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY841785292Medicaid