Healthcare Provider Details

I. General information

NPI: 1669805305
Provider Name (Legal Business Name): KELLY JANE-BALDWIN WATSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KELLY JANE BALDWIN

II. Dates (important events)

Enumeration Date: 08/16/2013
Last Update Date: 06/09/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 S TUSTIN ST
ORANGE CA
92866-3425
US

IV. Provider business mailing address

700 S TUSTIN ST
ORANGE CA
92866-3425
US

V. Phone/Fax

Practice location:
  • Phone: 714-922-4100
  • Fax: 714-633-1784
Mailing address:
  • Phone: 714-922-4100
  • Fax: 714-633-1784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA23137
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: