Provider Demographics
NPI:1912274614
Name:WATSON, NAOMI D (PA-C)
Entity type:Individual
Prefix:
First Name:NAOMI
Middle Name:D
Last Name:WATSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176C W UNIVERSITY PKWY # C
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-1616
Mailing Address - Country:US
Mailing Address - Phone:731-660-6915
Mailing Address - Fax:731-668-4557
Practice Address - Street 1:176C W UNIVERSITY PKWY # C
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-1616
Practice Address - Country:US
Practice Address - Phone:731-660-6915
Practice Address - Fax:731-668-4557
Is Sole Proprietor?:No
Enumeration Date:2011-11-23
Last Update Date:2021-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1925363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1527825Medicaid