MEDICARE: MR. BERKLEY LEO WILLIAMS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	0110840786	VA

General Provider Information

NPI Number	:	1124319801
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BERKLEY LEO WILLIAMS PA-C

Provider Business Mailing Address
First Line	:	8708 SUDLEY RD
Second Line	:
City	:	MANASSAS
State	:	VA
Zip	:	20110-4405
Country	:	US
Telephone Number	:	703-530-1226
Fax Number	:	703-530-1228

Provider Business Practice Location Address
First Line	:	8708 SUDLEY RD
Second Line	:
City	:	MANASSAS
State	:	VA
Zip	:	20110-4405
Country	:	US
Telephone Number	:	703-530-1226
Fax Number	:	703-530-1228

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/28/2011
Last Update Date	:	04/28/2011

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