Healthcare Provider Details

I. General information

NPI: 1194720763
Provider Name (Legal Business Name): TRACY WOODROW WATSON JR. CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 07/13/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17638 WALNUT TRL
CHAGRIN FALLS OH
44023-6414
US

IV. Provider business mailing address

17638 WALNUT TRL
CHAGRIN FALLS OH
44023-6414
US

V. Phone/Fax

Practice location:
  • Phone: 440-708-2964
  • Fax: 440-708-0254
Mailing address:
  • Phone: 440-708-2964
  • Fax: 440-708-0254

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA03676
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN176205
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: