Provider Demographics
NPI:1982626362
Name:WATKINS, GREGORY SCOTT (PA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:SCOTT
Last Name:WATKINS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2829 UNIVERSITY AVE SE STE 730
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414-3279
Mailing Address - Country:US
Mailing Address - Phone:612-439-1867
Mailing Address - Fax:
Practice Address - Street 1:2855 CAMPUS DR
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MN
Practice Address - Zip Code:55441-2649
Practice Address - Country:US
Practice Address - Phone:763-577-7179
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2022-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN9194363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN448949700Medicaid