=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104395375
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILLIAM RAY WATKINS JR. RN, MSN, NP
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/17/2018
-----------------------------------------------------
Last Update Date | 11/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 214 HANGING ROCK HWY
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25601-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-784-5404
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 214 HANGING ROCK HWY
-----------------------------------------------------
City | LOGAN
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25601-5102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-784-4995
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 80052
-----------------------------------------------------
License Number State | WV
-----------------------------------------------------