Healthcare Provider Details

I. General information

NPI: 1790774537
Provider Name (Legal Business Name): SUSAN LEE WATKINS FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 MURPHY RD
MEDFORD OR
97504-8425
US

IV. Provider business mailing address

707 MURPHY RD
MEDFORD OR
97504-8425
US

V. Phone/Fax

Practice location:
  • Phone: 541-890-8900
  • Fax: 541-622-8901
Mailing address:
  • Phone: 541-622-8900
  • Fax: 541-622-8901

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200350114NP FNP PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: