Provider Demographics
NPI:1013196971
Name:WILLIAMS, JEFFERY ALAN
Entity Type:Individual
Prefix:
First Name:JEFFERY
Middle Name:ALAN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1549 MARTY CIR
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84084-2411
Mailing Address - Country:US
Mailing Address - Phone:801-580-4948
Mailing Address - Fax:
Practice Address - Street 1:1130 MAJOR AVE
Practice Address - Street 2:FREMONT FAMILY PRACTICE
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2342
Practice Address - Country:US
Practice Address - Phone:307-856-7800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-29
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 2592363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant