Basic Information
| Provider Information | |||||||||
| NPI: | 1265742662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2620 EAST BARNETT ROAD | ||||||||
| Address2: | SUITE H | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417894281 | ||||||||
| FaxNumber: | 5417895538 | ||||||||
| Practice Location | |||||||||
| Address1: | 691 MURPHY ROAD | ||||||||
| Address2: | SUITE 107 | ||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975048383 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417896460 | ||||||||
| FaxNumber: | 5417896461 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2010 | ||||||||
| LastUpdateDate: | 10/15/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA152965 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.