Healthcare Provider Details

I. General information

NPI: 1336127950
Provider Name (Legal Business Name): STEVE D WATTON PA C
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 S PARK ST PARK STREET MEDICAL CLINIC
GENOA NE
68640-3036
US

IV. Provider business mailing address

PO BOX 310 505 SO PARK ST PARK STREET MEDICAL CLINIC
GENOA NE
68640-0310
US

V. Phone/Fax

Practice location:
  • Phone: 402-993-2206
  • Fax: 402-993-2595
Mailing address:
  • Phone: 402-993-2206
  • Fax: 402-993-2595

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number519
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: