Healthcare Provider Details

I. General information

NPI: 1255685509
Provider Name (Legal Business Name): MS. TAMMY GAY WATSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 03/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3975 GOLDFINCH ST STE 1
SAN DIEGO CA
92103-2994
US

IV. Provider business mailing address

3975 GOLDFINCH ST STE 1
SAN DIEGO CA
92103-2994
US

V. Phone/Fax

Practice location:
  • Phone: 858-483-4247
  • Fax: 858-724-3015
Mailing address:
  • Phone: 858-483-4247
  • Fax: 858-724-3015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code335E00000X
TaxonomyProsthetic/Orthotic Supplier
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: