Basic Information
| Provider Information | |||||||||
| NPI: | 1578966073 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1616 N MAIN ST | ||||||||
| Address2: | STE 100A | ||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767839752 | ||||||||
| FaxNumber: | 2767837786 | ||||||||
| Practice Location | |||||||||
| Address1: | 1616 N MAIN ST | ||||||||
| Address2: | STE 100A | ||||||||
| City: | MARION | ||||||||
| State: | VA | ||||||||
| PostalCode: | 243544473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2767839752 | ||||||||
| FaxNumber: | 2767837786 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2014 | ||||||||
| LastUpdateDate: | 03/20/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2614 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | Q008775 | 05 | TN | MEDICAID |