Healthcare Provider Details

I. General information

NPI: 1801877022
Provider Name (Legal Business Name): BENJAMIN P WATTS M.H.S., PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2005
Last Update Date: 03/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3615 HOSPITAL ST
PASCAGOULA MS
39581-4112
US

IV. Provider business mailing address

6300 E LAKE BLVD STE. 301
VANCLEAVE MS
39565-6770
US

V. Phone/Fax

Practice location:
  • Phone: 228-762-3664
  • Fax: 228-769-7015
Mailing address:
  • Phone: 228-230-2663
  • Fax: 228-206-1192

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA-183
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA00164
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: