Healthcare Provider Details

I. General information

NPI: 1861436990
Provider Name (Legal Business Name): MICHAEL R. WILLIAMS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2006
Last Update Date: 08/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1850 CHADWICK DR
JACKSON MS
39204-3404
US

IV. Provider business mailing address

PO BOX 588
CANTON MS
39046-0588
US

V. Phone/Fax

Practice location:
  • Phone: 904-805-1300
  • Fax: 904-805-1302
Mailing address:
  • Phone: 904-805-1300
  • Fax: 904-805-1302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR754167
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: