Provider Demographics
NPI:1083668461
Name:WATSON, JOY M (PA)
Entity type:Individual
Prefix:
First Name:JOY
Middle Name:M
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:JOY
Other - Middle Name:M
Other - Last Name:HENDRICKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:4909 N GLEN PARK PLACE RD
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61614-4676
Mailing Address - Country:US
Mailing Address - Phone:309-674-7546
Mailing Address - Fax:
Practice Address - Street 1:4909 N GLEN PARK PLACE RD
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61614-4676
Practice Address - Country:US
Practice Address - Phone:309-674-7546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2009-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001638363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant