Healthcare Provider Details

I. General information

NPI: 1326197740
Provider Name (Legal Business Name): BLYTHE J WATSON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 10/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

811 13TH ST STE 20
AUGUSTA GA
30901-2771
US

IV. Provider business mailing address

811 13TH ST STE 20
AUGUSTA GA
30901-2771
US

V. Phone/Fax

Practice location:
  • Phone: 706-722-3401
  • Fax: 706-724-6540
Mailing address:
  • Phone: 706-722-3401
  • Fax: 706-724-6540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number0005551
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: