=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639894710
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GENA NICOLE WILLIAMS PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/11/2022
-----------------------------------------------------
Last Update Date | 07/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1109 GROSSER RD
-----------------------------------------------------
City | GILBERTSVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19525-9228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 484-498-6060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 222 S BROAD MOUNTAIN AVE
-----------------------------------------------------
City | FRACKVILLE
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 17931-2202
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 570-985-4318
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | MA064087
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | MA064087
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------