Basic Information
| Provider Information | |||||||||
| NPI: | 1942677869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | BRICKLIN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4201 | ||||||||
| Address2: | |||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334424201 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542745619 | ||||||||
| FaxNumber: | 7542275792 | ||||||||
| Practice Location | |||||||||
| Address1: | 3467 W HILLSBORO BLVD | ||||||||
| Address2: | SUITE B | ||||||||
| City: | DEERFIELD BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334429473 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542745619 | ||||||||
| FaxNumber: | 7542275792 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/26/2015 | ||||||||
| LastUpdateDate: | 12/20/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/20/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZC0007X | 15-450 | FL | N | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Certified First Assistant | 363AS0400X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 15-450 | 01 | FL | AMERICAN BOARD OF SURGICAL ASSITANTS | OTHER |