Provider Demographics
NPI:1902475627
Name:WATSON, AMANDA (PA-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-713-5215
Mailing Address - Fax:336-716-0030
Practice Address - Street 1:1370 W D ST
Practice Address - Street 2:
Practice Address - City:NORTH WILKESBORO
Practice Address - State:NC
Practice Address - Zip Code:28659-3506
Practice Address - Country:US
Practice Address - Phone:336-651-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-18
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-11368363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant