Provider Demographics
NPI:1346395712
Name:WILLIAMS, ALAN (PT)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 12TH AVE RD
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83686-6311
Mailing Address - Country:US
Mailing Address - Phone:208-463-0022
Mailing Address - Fax:208-463-0031
Practice Address - Street 1:2005 12TH AVE RD
Practice Address - Street 2:
Practice Address - City:NAMPA
Practice Address - State:ID
Practice Address - Zip Code:83686-6311
Practice Address - Country:US
Practice Address - Phone:208-463-0022
Practice Address - Fax:208-463-0031
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT576225100000X
IDOT129225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004407500Medicaid
ID1650761Medicare ID - Type Unspecified