Provider Demographics
NPI:1609012541
Name:WATSON, SUZANNE LEE (LMT)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:LEE
Last Name:WATSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2190 POPLAR DRIVE
Mailing Address - Street 2:STE 67
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504
Mailing Address - Country:US
Mailing Address - Phone:541-944-9321
Mailing Address - Fax:
Practice Address - Street 1:2190 POPLAR DR
Practice Address - Street 2:STE 67
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4655
Practice Address - Country:US
Practice Address - Phone:541-944-9321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-24
Last Update Date:2008-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR15470174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist