Provider Demographics
NPI:1275133340
Name:WILLIAMS, MARK ALAN (SURGICAL ASSISTANT)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ALAN
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:SURGICAL ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:201 WALKER AVE APT E
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374-2143
Mailing Address - Country:US
Mailing Address - Phone:413-326-6070
Mailing Address - Fax:
Practice Address - Street 1:4814 LAKE LIVINGSTON DR
Practice Address - Street 2:
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78413-5139
Practice Address - Country:US
Practice Address - Phone:361-813-0160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-28
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical