Healthcare Provider Details

I. General information

NPI: 1821253683
Provider Name (Legal Business Name): JONATHAN KEITH WILLIAMS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2008
Last Update Date: 10/15/2021
Certification Date: 10/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 WASHINGTON PARKWAY
IDAHO FALLS ID
83404-7596
US

IV. Provider business mailing address

3910 WASHINGTON PARKWAY
IDAHO FALLS ID
83404-7596
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1122
  • Fax: 208-523-2582
Mailing address:
  • Phone: 208-523-1122
  • Fax: 208-523-2582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-871A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: