Healthcare Provider Details

I. General information

NPI: 1770952095
Provider Name (Legal Business Name): MARA LEONE WILLIAMS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2015
Last Update Date: 07/21/2022
Certification Date: 07/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8025 EXCELSIOR DR #110
MADISON WI
53717-1900
US

IV. Provider business mailing address

2840 INDEX RD
FITCHBURG WI
53713-3117
US

V. Phone/Fax

Practice location:
  • Phone: 608-663-6154
  • Fax:
Mailing address:
  • Phone: 608-440-1682
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5858
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: