Provider Demographics
NPI:1417330341
Name:WATSON, JUSTINE ANNISSA-MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:JUSTINE
Middle Name:ANNISSA-MARIE
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA-C
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Mailing Address - Street 1:12251 S 80TH AVE STE 1520
Mailing Address - Street 2:
Mailing Address - City:PALOS HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60463-1290
Mailing Address - Country:US
Mailing Address - Phone:708-923-4200
Mailing Address - Fax:708-923-4201
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 5A43
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-2200
Practice Address - Country:US
Practice Address - Phone:302-623-0188
Practice Address - Fax:302-733-5640
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2024-06-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
DEC5-0001071363A00000X
IL085010236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant