Healthcare Provider Details

I. General information

NPI: 1194836726
Provider Name (Legal Business Name): BRANDON W. WILLIAMS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2000 10TH AVE SUITE 270
COLUMBUS GA
31901-3700
US

IV. Provider business mailing address

PO BOX 370
FORTSON GA
31808-0370
US

V. Phone/Fax

Practice location:
  • Phone: 706-571-1011
  • Fax: 706-320-8646
Mailing address:
  • Phone:
  • Fax: 706-494-3008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number005072
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number005072
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberPAT9103786
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: