Healthcare Provider Details

I. General information

NPI: 1336460369
Provider Name (Legal Business Name): STEPHEN W WATKINS CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2010
Last Update Date: 06/30/2020
Certification Date: 06/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3705 MEDICAL PKWY SUITE 570
AUSTIN TX
78705-1019
US

IV. Provider business mailing address

PO BOX 840853
DALLAS TX
75284-1019
US

V. Phone/Fax

Practice location:
  • Phone: 512-454-2554
  • Fax:
Mailing address:
  • Phone: 972-233-1999
  • Fax: 972-233-3666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number537967
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberAP119105
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: