Healthcare Provider Details

I. General information

NPI: 1760072557
Provider Name (Legal Business Name): KEVIN JAMES WATSON NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2021
Last Update Date: 06/16/2026
Certification Date: 06/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 3RD AVE E
TWIN FALLS ID
83301-6252
US

IV. Provider business mailing address

207 3RD AVE E
TWIN FALLS ID
83301-6252
US

V. Phone/Fax

Practice location:
  • Phone: 661-333-3194
  • Fax: 606-755-3289
Mailing address:
  • Phone: 661-333-3194
  • Fax: 606-755-3289

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number77227
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015235
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: