Provider Demographics
NPI:1952924631
Name:WATTS, SHANICE RENEE (PA-C)
Entity Type:Individual
Prefix:
First Name:SHANICE
Middle Name:RENEE
Last Name:WATTS
Suffix:
Gender:F
Credentials:PA-C
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Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:6399 SAN IGNACIO AVE STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95119-1215
Mailing Address - Country:US
Mailing Address - Phone:707-805-3234
Mailing Address - Fax:
Practice Address - Street 1:9460 N NAME UNO STE 210
Practice Address - Street 2:
Practice Address - City:GILROY
Practice Address - State:CA
Practice Address - Zip Code:95020-3532
Practice Address - Country:US
Practice Address - Phone:408-847-0888
Practice Address - Fax:408-847-1257
Is Sole Proprietor?:Yes
Enumeration Date:2020-05-28
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA59811363A00000X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant