Basic Information
| Provider Information | |||||||||
| NPI: | 1255563573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 281 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | BRODNAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 239202745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2525295171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1755 N MECKLENBURG AVE | ||||||||
| Address2: | |||||||||
| City: | LA CROSSE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 23950 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4344473151 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2009 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/11/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12111 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2305206870 | VA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.