Provider Demographics
NPI:1265024830
Name:WILLIAMS, SAMUEL K
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:K
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 1:3660 42ND ST S APT 200
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-7440
Mailing Address - Country:US
Mailing Address - Phone:763-339-8302
Mailing Address - Fax:
Practice Address - Street 1:3660 42ND ST S APT 2003660
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-7438
Practice Address - Country:US
Practice Address - Phone:763-339-8302
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14769373747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1476937Medicaid