Healthcare Provider Details

I. General information

NPI: 1730928649
Provider Name (Legal Business Name): TRAE WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2024
Last Update Date: 07/14/2026
Certification Date: 07/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

559 VINCENT ST SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914
US

IV. Provider business mailing address

559 VINCENT ST SPACE BASE DELTA 1
PETERSON SPACE FORCE BASE CO
80914
US

V. Phone/Fax

Practice location:
  • Phone: 720-628-6697
  • Fax:
Mailing address:
  • Phone: 720-628-6697
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: