Provider Demographics
NPI:1447842448
Name:WATSON, SAM
Entity type:Individual
Prefix:
First Name:SAM
Middle Name:
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 1:903 KAREN AVE
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-7215
Mailing Address - Country:US
Mailing Address - Phone:918-864-9904
Mailing Address - Fax:
Practice Address - Street 1:6216 S LEWIS AVE STE 102
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74136-1075
Practice Address - Country:US
Practice Address - Phone:918-416-4483
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-10
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator