Healthcare Provider Details

I. General information

NPI: 1306731054
Provider Name (Legal Business Name): CORY WATSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2025
Last Update Date: 06/01/2026
Certification Date: 06/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 INTEGRIS PKWY
EDMOND OK
73034-8864
US

IV. Provider business mailing address

1837 KINGS XING
EDMOND OK
73013-4314
US

V. Phone/Fax

Practice location:
  • Phone: 405-657-3000
  • Fax:
Mailing address:
  • Phone: 405-850-0975
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number224154
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: