Basic Information
| Provider Information | |||||||||
| NPI: | 1790979805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WATSON | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2699 | ||||||||
| Address2: | |||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325132699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504166159 | ||||||||
| FaxNumber: | 8504754619 | ||||||||
| Practice Location | |||||||||
| Address1: | 5149 N 9TH AVE | ||||||||
| Address2: | SUITE 246 | ||||||||
| City: | PENSACOLA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325048756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8504166159 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2007 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA9107263 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3677 | 01 | AZ | STATE LICENSE | OTHER | PA-562 | 01 | AL | STATE LICENSE | OTHER |