Healthcare Provider Details

I. General information

NPI: 1275133340
Provider Name (Legal Business Name): MARK ALAN WILLIAMS SURGICAL ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/28/2020
Last Update Date: 10/28/2020
Certification Date: 10/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4814 LAKE LIVINGSTON DR
CORPUS CHRISTI TX
78413-5139
US

IV. Provider business mailing address

201 WALKER AVE APT E
PORTLAND TX
78374-2143
US

V. Phone/Fax

Practice location:
  • Phone: 361-813-0160
  • Fax:
Mailing address:
  • Phone: 413-326-6070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: