Healthcare Provider Details

I. General information

NPI: 1194030809
Provider Name (Legal Business Name): BRANDON WELLS WATSON PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2010
Last Update Date: 08/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 W MADISON AVE
ATHENS TN
37303-4150
US

IV. Provider business mailing address

PO BOX 634760
CINCINNATI OH
45263-4760
US

V. Phone/Fax

Practice location:
  • Phone: 423-745-1411
  • Fax:
Mailing address:
  • Phone: 865-539-8000
  • Fax: 865-539-8008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA1864
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: