Healthcare Provider Details

I. General information

NPI: 1790757771
Provider Name (Legal Business Name): KORY LYNNE WILLIAMS P.A.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 06/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 BURNETT COURT STE 100
DURANGO CO
81301-3647
US

IV. Provider business mailing address

2 BURNETT COURT STE 100
DURANGO CO
81301-3647
US

V. Phone/Fax

Practice location:
  • Phone: 970-385-4022
  • Fax: 970-385-4337
Mailing address:
  • Phone: 970-385-4022
  • Fax: 970-385-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number1544
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1544
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: