Healthcare Provider Details

I. General information

NPI: 1427166040
Provider Name (Legal Business Name): MARY JO WATTS CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/25/2006
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 TREELINE PARK
SAN ANTONIO TX
78209-2042
US

IV. Provider business mailing address

1245 PRAIRIE BND STE 900
NEW BRAUNFELS TX
78132-2966
US

V. Phone/Fax

Practice location:
  • Phone: 210-294-8000
  • Fax:
Mailing address:
  • Phone: 757-813-7988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number794938
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: