Healthcare Provider Details

I. General information

NPI: 1356703276
Provider Name (Legal Business Name): KATHERINE MARIE WATSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3433 BROADWAY ST NE STE 115
MINNEAPOLIS MN
55413-1759
US

IV. Provider business mailing address

3433 BROADWAY ST NE STE 115
MINNEAPOLIS MN
55413-1759
US

V. Phone/Fax

Practice location:
  • Phone: 612-624-1722
  • Fax:
Mailing address:
  • Phone: 612-624-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number71345
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number71345
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: