Healthcare Provider Details

I. General information

NPI: 1295003374
Provider Name (Legal Business Name): JENNIFER ROSE WATRY PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/05/2011
Last Update Date: 06/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9735 N 90TH PL
SCOTTSDALE AZ
85258
US

IV. Provider business mailing address

9735 N 90TH PL
SCOTTSDALE AZ
85258-5067
US

V. Phone/Fax

Practice location:
  • Phone: 480-222-4954
  • Fax: 602-297-6556
Mailing address:
  • Phone: 480-222-4954
  • Fax: 602-297-6556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number5013
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: