Provider Demographics
NPI:1538156336
Name:WATSON, GRETA J (PA)
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:J
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:J
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4050 W MEMORIAL RD
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8382
Mailing Address - Country:US
Mailing Address - Phone:405-608-3800
Mailing Address - Fax:405-608-3838
Practice Address - Street 1:4050 W MEMORIAL RD
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8382
Practice Address - Country:US
Practice Address - Phone:405-608-3800
Practice Address - Fax:405-608-3838
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK421363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100102180AMedicaid
OK100102180AMedicaid
OKOKA102045Medicare PIN
OKP11791Medicare UPIN
OK24H616516Medicare PIN
OKOKA100673Medicare PIN