=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902851041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RUFUS DELRO WILLIAMS JR. M.P.A.S., PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4420 LAKE BOONE TRL
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-7505
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-784-3038
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX K
-----------------------------------------------------
City | GOLDSBORO
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27533-9710
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-580-0004
-----------------------------------------------------
Fax | 919-580-9224
-----------------------------------------------------
=====================================================
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 | 000102896
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------