Provider Demographics
NPI:1730695412
Name:WATANABE, MIO (PA-C)
Entity type:Individual
Prefix:
First Name:MIO
Middle Name:
Last Name:WATANABE
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:PO BOX 5210
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-5210
Mailing Address - Country:US
Mailing Address - Phone:701-205-3000
Mailing Address - Fax:701-732-2501
Practice Address - Street 1:4700 S WASHINGTON ST STE G
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-8123
Practice Address - Country:US
Practice Address - Phone:701-205-3000
Practice Address - Fax:701-732-2501
Is Sole Proprietor?:No
Enumeration Date:2017-12-18
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT105968801206363A00000X
MN13106363A00000X
AK141585363A00000X
NDPAC0794363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1693549Medicaid
MN1730695412Medicaid
ND1478025Medicaid