Healthcare Provider Details

I. General information

NPI: 1538043567
Provider Name (Legal Business Name): ADDISSON RANDALL WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2025
Last Update Date: 08/04/2025
Certification Date: 08/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19432 KISTLER FARM RD
DAVIDSON NC
28036-9007
US

IV. Provider business mailing address

19432 KISTLER FARM RD
DAVIDSON NC
28036-9007
US

V. Phone/Fax

Practice location:
  • Phone: 704-918-8868
  • Fax:
Mailing address:
  • Phone: 704-918-8868
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: