MEDICARE: MS. BROOKE ELIZABETH WATSON PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1114402153
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. BROOKE ELIZABETH WATSON PA-C

Provider Business Mailing Address
First Line	:	PO BOX 530062
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30353-0062
Country	:	US
Telephone Number	:	843-695-6071
Fax Number	:	843-569-5881

Provider Business Practice Location Address
First Line	:	5500 FRONT ST STE 260
Second Line	:
City	:	SUMMERVILLE
State	:	SC
Zip	:	29486-8140
Country	:	US
Telephone Number	:	843-576-0700
Fax Number	:	843-576-0701

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/25/2018
Last Update Date	:	06/15/2022

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