Healthcare Provider Details

I. General information

NPI: 1972166114
Provider Name (Legal Business Name): DARTHVADER DEVON WILLIAMSON RSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2019
Last Update Date: 04/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2986 KATE BOND RD
BARTLETT TN
38133-4003
US

IV. Provider business mailing address

13560 HIGHWAY 196
EADS TN
38028-3606
US

V. Phone/Fax

Practice location:
  • Phone: 901-820-7468
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberMAS0000000047
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
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: