Provider Demographics
NPI:1477306934
Name:WILLIAMS, TAZARIYA
Entity Type:Individual
Prefix:
First Name:TAZARIYA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4665 OMAHA BEACH ST
Mailing Address - Street 2:
Mailing Address - City:FORT IRWIN
Mailing Address - State:CA
Mailing Address - Zip Code:92310-1914
Mailing Address - Country:US
Mailing Address - Phone:254-290-9826
Mailing Address - Fax:
Practice Address - Street 1:4665 OMAHA BEACH ST
Practice Address - Street 2:
Practice Address - City:FORT IRWIN
Practice Address - State:CA
Practice Address - Zip Code:92310-1914
Practice Address - Country:US
Practice Address - Phone:254-290-9826
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-05
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000040546093367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered