Provider Demographics
NPI:1346356649
Name:WILLIAMS, IDA C (CRNA)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:C
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3711 A PL
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-1316
Mailing Address - Country:US
Mailing Address - Phone:601-482-0092
Mailing Address - Fax:
Practice Address - Street 1:2124 14TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4040
Practice Address - Country:US
Practice Address - Phone:601-553-6000
Practice Address - Fax:601-553-6115
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR098780367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00110075Medicaid
AL730-03794OtherBLUE CROSS OF AL
MS00110075Medicaid