Healthcare Provider Details

I. General information

NPI: 1013973205
Provider Name (Legal Business Name): SHELDON BURDELL WATSON PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2006
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MADIGAN ARMY MEDICAL CENTER/OKUBO CLINIC 9040 JACKSON AVE
TACOMA WA
98431-1730
US

IV. Provider business mailing address

412 AMDS/SGPF 30 NIGHTINGALE RD
EDWARDS AFB CA
93534-1730
US

V. Phone/Fax

Practice location:
  • Phone: 253-966-7546
  • Fax:
Mailing address:
  • Phone: 661-277-2575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1036622
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: