Healthcare Provider Details

I. General information

NPI: 1255746962
Provider Name (Legal Business Name): JOHN WATSON JR. NP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/23/2014
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 S ELLIOTT ST
PRYOR OK
74361-6421
US

IV. Provider business mailing address

510 S ELLIOTT ST
PRYOR OK
74361-6421
US

V. Phone/Fax

Practice location:
  • Phone: 918-825-3777
  • Fax: 918-825-3776
Mailing address:
  • Phone: 918-825-3777
  • Fax: 918-825-3776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number99514
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: