=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407555360
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ZACHARY MARSHALL WILLIAMS FNP-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/01/2023
-----------------------------------------------------
Last Update Date | 03/13/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 VISION PARK BLVD STE 200
-----------------------------------------------------
City | SHENANDOAH
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77384-3027
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 281-725-6767
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8840 LAKESHORE DR
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 77316-2400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 962690
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1112778
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------