Provider Demographics
NPI:1497747273
Name:WILLIAMS, TED MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:MICHAEL
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 846098
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-6098
Mailing Address - Country:US
Mailing Address - Phone:903-324-6400
Mailing Address - Fax:
Practice Address - Street 1:703 S FLEISHEL AVE STE 4000
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75701-2015
Practice Address - Country:US
Practice Address - Phone:903-606-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04514363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX184590102Medicaid
TX75-2616977-042OtherTRICARE
TX836N57OtherBCBS
TX8N8739OtherBCBS OF TEXAS
TX184590101Medicaid
TX184590102Medicaid
TX184590101Medicaid
TXP00925624Medicare Oscar/Certification
TX8D9081Medicare PIN
TXP00349355Medicare PIN