Basic Information
| Provider Information | |||||||||
| NPI: | 1083078265 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | COREY | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4399 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084399 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5034133900 | ||||||||
| FaxNumber: | 5034133710 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 NE 2ND AVE | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5039448000 | ||||||||
| FaxNumber: | 5039448017 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2016 | ||||||||
| LastUpdateDate: | 04/08/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 2016012318 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0808X | 234275-3 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 201810266NP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.