=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265742662
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK WILLIAMS PA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2010
-----------------------------------------------------
Last Update Date | 10/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 691 MURPHY ROAD SUITE 107
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97504-8383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-789-6460
-----------------------------------------------------
Fax | 541-789-6461
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2620 EAST BARNETT ROAD SUITE H
-----------------------------------------------------
City | MEDFORD
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97504-8383
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-789-4281
-----------------------------------------------------
Fax | 541-789-5538
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA152965
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------