Provider Demographics
NPI:1871052050
Name:WATSON, IAN (NP)
Entity type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:WATSON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5410 MARYLAND WAY STE 300
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5339
Mailing Address - Country:US
Mailing Address - Phone:615-377-1705
Mailing Address - Fax:
Practice Address - Street 1:2600 SAINT MICHAEL DR
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-5220
Practice Address - Country:US
Practice Address - Phone:903-614-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MECNP211618363L00000X
TXAP141005363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXAP141005OtherSTATE LICENSE