Basic Information
| Provider Information | |||||||||
| NPI: | 1588671978 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 43151 DALCOMA DR STE 4 | ||||||||
| Address2: | |||||||||
| City: | CLINTON TWP | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480386306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5862868720 | ||||||||
| FaxNumber: | 5866496699 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 KEEWAHDIN RD | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480593526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8104551600 | ||||||||
| FaxNumber: | 8104551620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2006 | ||||||||
| LastUpdateDate: | 04/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 5601003406 | MI | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.