Provider Demographics
NPI:1730227299
Name:WATSON, PHILIP DEAN (PA)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:DEAN
Last Name:WATSON
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1203 E ROSS BYP
Mailing Address - Street 2:SUITE A
Mailing Address - City:TAHLEQUAH
Mailing Address - State:OK
Mailing Address - Zip Code:74464-4133
Mailing Address - Country:US
Mailing Address - Phone:918-453-1234
Mailing Address - Fax:918-453-9107
Practice Address - Street 1:1203 E ROSS BYP
Practice Address - Street 2:SUITE A
Practice Address - City:TAHLEQUAH
Practice Address - State:OK
Practice Address - Zip Code:74464-4133
Practice Address - Country:US
Practice Address - Phone:918-453-1234
Practice Address - Fax:918-453-9107
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-04
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1463363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200070490 AMedicaid
OK200129810AMedicaid
OK200070490 AMedicaid