Healthcare Provider Details

I. General information

NPI: 1730963828
Provider Name (Legal Business Name): ELYSSA WATTS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2023
Last Update Date: 09/27/2023
Certification Date: 09/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1215 E MICHIGAN AVE
LANSING MI
48912-1896
US

IV. Provider business mailing address

2173 IROQUOIS RD
OKEMOS MI
48864-1011
US

V. Phone/Fax

Practice location:
  • Phone: 517-364-1000
  • Fax:
Mailing address:
  • Phone: 616-490-3221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5601011987
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: