Healthcare Provider Details

I. General information

NPI: 1477664944
Provider Name (Legal Business Name): KENNETH EARL WILLIAMS I P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

IV. Provider business mailing address

1501 SAN PEDRO DR SE
ALBUQUERQUE NM
87108-5153
US

V. Phone/Fax

Practice location:
  • Phone: 505-256-5746
  • Fax: 505-256-5772
Mailing address:
  • Phone: 505-256-5746
  • Fax: 505-256-5772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number80-PA018
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: