Healthcare Provider Details

I. General information

NPI: 1154034031
Provider Name (Legal Business Name): PAUL WATTERSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 03/20/2024
Certification Date: 03/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MARTIN LUTHER KING JR WAY
TACOMA WA
98405-4234
US

IV. Provider business mailing address

PO BOX 5299 MS: 820-5-PCO
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-406-1000
  • Fax: 253-864-2779
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61462197
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: