Healthcare Provider Details

I. General information

NPI: 1215475306
Provider Name (Legal Business Name): TRENTON WATSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2017
Last Update Date: 02/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

533 SHADOW WOOD DR
SMITHS STATION AL
36877-4836
US

IV. Provider business mailing address

533 SHADOW WOOD DR
SMITHS STATION AL
36877-4836
US

V. Phone/Fax

Practice location:
  • Phone: 850-814-4107
  • Fax:
Mailing address:
  • Phone: 850-814-4107
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number244202
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number1-107743
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: