Provider Demographics
NPI:1194159350
Name:WATSON, NICOLE LOUISE (PA-C, MPAS)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LOUISE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 N RAINBOW BLVD STE 203
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89107-1084
Mailing Address - Country:US
Mailing Address - Phone:702-259-1228
Mailing Address - Fax:702-259-1252
Practice Address - Street 1:620 SHADOW LN
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89106-4119
Practice Address - Country:US
Practice Address - Phone:023-884-0007
Practice Address - Fax:702-476-2040
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23154363AS0400X
NV1628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical