Provider Demographics
NPI:1265457527
Name:WILLIAMS, HENRY MALONE JR (PA)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:MALONE
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5875 BREMO RD
Mailing Address - Street 2:SUITE G-5
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23226-1934
Mailing Address - Country:US
Mailing Address - Phone:804-287-7840
Mailing Address - Fax:804-287-7845
Practice Address - Street 1:5875 BREMO RD
Practice Address - Street 2:SUITE G-5
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23226-1934
Practice Address - Country:US
Practice Address - Phone:804-287-7840
Practice Address - Fax:804-287-7845
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00752363AS0400X
VA0101002839363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX180134201Medicaid
TX8397J5OtherBLUE CROSS BLUE SHIELD
TX970018025OtherRAILROAD MEDICARE
VAMW1014339OtherDEA
TX8397J5OtherBLUE CROSS BLUE SHIELD
TXP12077Medicare UPIN