Healthcare Provider Details

I. General information

NPI: 1730227299
Provider Name (Legal Business Name): PHILIP DEAN WATSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2007
Last Update Date: 08/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1203 E ROSS BYP SUITE A
TAHLEQUAH OK
74464-4133
US

IV. Provider business mailing address

1203 E ROSS BYP SUITE A
TAHLEQUAH OK
74464-4133
US

V. Phone/Fax

Practice location:
  • Phone: 918-453-1234
  • Fax: 918-453-9107
Mailing address:
  • Phone: 918-453-1234
  • Fax: 918-453-9107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1463
License Number StateOK

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier200070490 A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer
# 2
Identifier200129810A
Identifier TypeMEDICAID
Identifier StateOK
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: