Healthcare Provider Details

I. General information

NPI: 1235094848
Provider Name (Legal Business Name): CONNOR MICHAEL WILLIAMSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 LATHROP ST
FAIRBANKS AK
99701-7426
US

IV. Provider business mailing address

3420 MINK LN
FAIRBANKS AK
99712-3320
US

V. Phone/Fax

Practice location:
  • Phone: 907-474-0890
  • Fax:
Mailing address:
  • Phone: 907-370-9415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: