Provider Demographics
NPI:1407017031
Name:WILLIAMS, RICHARD LEE (PA)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
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 1:1315 BROOKSIDE DR
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-3942
Mailing Address - Country:US
Mailing Address - Phone:817-268-7982
Mailing Address - Fax:888-331-3527
Practice Address - Street 1:1315 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-3942
Practice Address - Country:US
Practice Address - Phone:817-268-7982
Practice Address - Fax:888-331-3527
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA05825363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTIN PLUS 008OtherTRICARE
TX195448901Medicaid
TX8Y8586OtherBCBS OF TEXAS
TX8L17553Medicare PIN
TX8L17552Medicare PIN
TX195448901Medicaid
TX8L0631Medicare Oscar/Certification