Provider Demographics
NPI:1417049420
Name:WILLIAMSON, THERESA (PA)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 PEE DEE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:ALBEMARLE
Mailing Address - State:NC
Mailing Address - Zip Code:28001-4932
Mailing Address - Country:US
Mailing Address - Phone:704-986-1500
Mailing Address - Fax:910-738-8230
Practice Address - Street 1:2003 GODWIN AVE
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3149
Practice Address - Country:US
Practice Address - Phone:910-674-4814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101678363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P91257Medicare UPIN