Basic Information
| Provider Information | |||||||||
| NPI: | 1164494605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MAUREEN | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLOTHIER | ||||||||
| OtherFirstName: | MAUREEN | ||||||||
| OtherMiddleName: | A | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1806 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094524520 | ||||||||
| FaxNumber: | 5094525224 | ||||||||
| Practice Location | |||||||||
| Address1: | 1806 W LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989022473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5094524520 | ||||||||
| FaxNumber: | 5094525224 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 07/30/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 34007976C | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207RG0300X | OP 60343920 | WA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2026194 | 05 | WA | MEDICAID |