Healthcare Provider Details

I. General information

NPI: 1699856344
Provider Name (Legal Business Name): STEPHEN M WILLIAMS PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 IDAHO STREET
GOODING ID
83330
US

IV. Provider business mailing address

PO BOX 447
GOODING ID
83330
US

V. Phone/Fax

Practice location:
  • Phone: 208-934-5900
  • Fax: 208-934-5719
Mailing address:
  • Phone: 208-934-5900
  • Fax: 208-934-5719

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA628
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: