Provider Demographics
NPI:1275263048
Name:WILLIAMS, TREVIN AHMADERIC
Entity Type:Individual
Prefix:
First Name:TREVIN
Middle Name:AHMADERIC
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 1:11812 REGISTRY BLVD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:GA
Mailing Address - Zip Code:30228-6393
Mailing Address - Country:US
Mailing Address - Phone:678-763-8374
Mailing Address - Fax:
Practice Address - Street 1:231 W HANCOCK ST
Practice Address - Street 2:
Practice Address - City:MILLEDGEVILLE
Practice Address - State:GA
Practice Address - Zip Code:31061-3371
Practice Address - Country:US
Practice Address - Phone:478-445-4072
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA990542163OtherCIGNA