MEDICARE: SARA WATSON

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1174907091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SARA WATSON

Provider Business Mailing Address
First Line	:	83 CHICKASAW TRL
Second Line	:
City	:	MEDFORD LAKES
State	:	NJ
Zip	:	08055-9703
Country	:	US
Telephone Number	:	609-304-6709
Fax Number	:

Provider Business Practice Location Address
First Line	:	126 E TENNESSEE AVE
Second Line	:
City	:	LONG BEACH TOWNSHIP
State	:	NJ
Zip	:	08008-3065
Country	:	US
Telephone Number	:	732-978-4856
Fax Number	:

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

Provider Enumeration Date	:	07/10/2015
Last Update Date	:	07/28/2015

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