Basic Information
| Provider Information | |||||||||
| NPI: | 1114484581 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | SHELBY | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376513000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 CHILDRENS PLZ | ||||||||
| Address2: | |||||||||
| City: | DAYTON | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454041815 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9376413600 | ||||||||
| FaxNumber: | 9376415802 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2019 | ||||||||
| LastUpdateDate: | 10/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.005952RX | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 0340092 | 05 | OH | MEDICAID |