MEDICARE: KENIA NICHELLE WATKINS PA

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	363AM0700X	Medical Physician Assistant	PA16377	CA

General Provider Information

NPI Number	:	1639464845
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KENIA NICHELLE WATKINS PA

Provider Business Mailing Address
First Line	:	4359 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-6236
Country	:	US
Telephone Number	:	323-569-6979
Fax Number	:	323-249-4626

Provider Business Practice Location Address
First Line	:	4359 TWEEDY BLVD
Second Line	:
City	:	SOUTH GATE
State	:	CA
Zip	:	90280-6236
Country	:	US
Telephone Number	:	323-569-6979
Fax Number	:	323-249-4626

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

Provider Enumeration Date	:	06/15/2011
Last Update Date	:	06/15/2011

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