Provider Demographics
NPI:1699090993
Name:WATSON, KENNETH LEE
Entity type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:LEE
Last Name:WATSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15032 POQUESSING CREEK LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19116-1531
Mailing Address - Country:US
Mailing Address - Phone:267-446-6521
Mailing Address - Fax:
Practice Address - Street 1:3401 N BROAD ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19140-5103
Practice Address - Country:US
Practice Address - Phone:215-707-3133
Practice Address - Fax:215-707-3945
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PATEI002569225200000X
NJ25MP00409400363A00000X
PAMA060559363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant