Healthcare Provider Details

I. General information

NPI: 1417079112
Provider Name (Legal Business Name): JAMES THOMAS WILLIAMS PHYSICIAN ASST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 02/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 MENDOCINO AVE
SANTA ROSA CA
95401-4804
US

IV. Provider business mailing address

4704 HOEN AVE
SANTA ROSA CA
95405-7824
US

V. Phone/Fax

Practice location:
  • Phone: 707-623-9803
  • Fax: 707-843-3257
Mailing address:
  • Phone: 707-546-7979
  • Fax: 707-546-7667

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA12244
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: