Healthcare Provider Details

I. General information

NPI: 1790369403
Provider Name (Legal Business Name): ADAM WILLIAMS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/09/2021
Last Update Date: 04/30/2025
Certification Date: 04/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 NORTH MEDICAL DRIVE 3RD FLOOR SOUTH
SALT LAKE CITY UT
84132-0001
US

IV. Provider business mailing address

30 NORTH MEDICAL DRIVE 3RD FLOOR SOUTH
SALT LAKE CITY UT
84132-0001
US

V. Phone/Fax

Practice location:
  • Phone: 801-646-7128
  • Fax:
Mailing address:
  • Phone: 801-646-7128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number13559362-1206
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: