MEDICARE: ANGELICA WATSON PT

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	225100000X	Physical Therapist	2790	NM

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2790	OTHER	NM	REG & LICENSING

General Provider Information

NPI Number	:	1821090820
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELICA WATSON PT

Provider Business Mailing Address
First Line	:	PO BOX 29269
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87592-9269
Country	:	US
Telephone Number	:	505-984-2032
Fax Number	:	505-984-0738

Provider Business Practice Location Address
First Line	:	786A N SAINT FRANCIS DR
Second Line	:
City	:	SANTA FE
State	:	NM
Zip	:	87501-5100
Country	:	US
Telephone Number	:	505-984-2032
Fax Number	:	505-984-0738

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/08/2007

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