Healthcare Provider Details

I. General information

NPI: 1518473313
Provider Name (Legal Business Name): SAMUEL COLIN WATKINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2017
Last Update Date: 12/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 20TH ST NW STE 116
WASHINGTON DC
20036-3406
US

IV. Provider business mailing address

401 12TH ST S
ARLINGTON VA
22202-4226
US

V. Phone/Fax

Practice location:
  • Phone: 202-416-2110
  • Fax:
Mailing address:
  • Phone: 206-595-3497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: