Healthcare Provider Details

I. General information

NPI: 1528624160
Provider Name (Legal Business Name): RAVEN SHANISE WILLIAMS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2019
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 N 7TH ST
WEST MEMPHIS AR
72301-2001
US

IV. Provider business mailing address

900 N 7TH ST
WEST MEMPHIS AR
72301-2001
US

V. Phone/Fax

Practice location:
  • Phone: 870-293-0594
  • Fax: 870-394-9476
Mailing address:
  • Phone: 870-735-3842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number8040
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA00656
License Number StateMS
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1504
License Number StateAR
# 4
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number6260
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: