Healthcare Provider Details

I. General information

NPI: 1679772388
Provider Name (Legal Business Name): WILLIE MACK WATTS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2007
Last Update Date: 06/13/2022
Certification Date: 06/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4292 GRAY HWY
GRAY GA
31032-5900
US

IV. Provider business mailing address

PO BOX 73
PORT ROYAL SC
29935-0073
US

V. Phone/Fax

Practice location:
  • Phone: 478-986-2500
  • Fax: 478-864-1288
Mailing address:
  • Phone: 256-393-9663
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA-184
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number10853
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: