Healthcare Provider Details

I. General information

NPI: 1891253092
Provider Name (Legal Business Name): THOMAS GEORGE WATTS FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2019
Last Update Date: 03/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4711 GOLF RD STE 1250
SKOKIE IL
60076-1232
US

IV. Provider business mailing address

9223 S HARDING AVE
EVERGREEN PARK IL
60805-1440
US

V. Phone/Fax

Practice location:
  • Phone: 847-235-6103
  • Fax:
Mailing address:
  • Phone: 708-673-3223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209.018870
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041.428148
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: