Provider Demographics
NPI:1194365585
Name:WILLIAMS, RANDALL BLAKE
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:BLAKE
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 1:22732 INTERSTATE 20 E
Mailing Address - Street 2:
Mailing Address - City:WINONA
Mailing Address - State:TX
Mailing Address - Zip Code:75792-6906
Mailing Address - Country:US
Mailing Address - Phone:903-539-0768
Mailing Address - Fax:
Practice Address - Street 1:3111 MCCANN RD
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-7842
Practice Address - Country:US
Practice Address - Phone:903-753-1212
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-14
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP144567363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty