Healthcare Provider Details

I. General information

NPI: 1548345473
Provider Name (Legal Business Name): NATHAN WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

66735 MARTINEZ ST
THERMAL CA
92274-9007
US

IV. Provider business mailing address

12197 WHITE ROCK DR
RANCHO CUCAMONGA CA
91739-9079
US

V. Phone/Fax

Practice location:
  • Phone: 800-717-4476
  • Fax:
Mailing address:
  • Phone: 909-899-7442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License NumberA79720
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: