Provider Demographics
NPI:1215245485
Name:WATTS, JENNIFER WYLIE (MS, PA-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:WYLIE
Last Name:WATTS
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5000 COX RD
Mailing Address - Street 2:
Mailing Address - City:GLEN ALLEN
Mailing Address - State:VA
Mailing Address - Zip Code:23060-9263
Mailing Address - Country:US
Mailing Address - Phone:804-968-5700
Mailing Address - Fax:
Practice Address - Street 1:995 HOSPITALITY WAY
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MD
Practice Address - Zip Code:21001-1755
Practice Address - Country:US
Practice Address - Phone:410-306-7880
Practice Address - Fax:410-306-7881
Is Sole Proprietor?:No
Enumeration Date:2010-09-21
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004361363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD541762TVZMedicare PIN
MD541762ZDDBMedicare PIN
MD541895YWV2Medicare PIN