Provider Demographics
NPI:1508864299
Name:WILLIAMSON, WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:WAYNE
Middle Name:
Last Name:WILLIAMSON
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 1:2930 11TH AVE
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:CO
Mailing Address - Zip Code:80620-1011
Mailing Address - Country:US
Mailing Address - Phone:970-353-9403
Mailing Address - Fax:970-350-4645
Practice Address - Street 1:302 3RD ST SE
Practice Address - Street 2:SUITE 150
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80537-6419
Practice Address - Country:US
Practice Address - Phone:970-669-4855
Practice Address - Fax:970-669-7389
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2014-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO97363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07079007Medicaid
Q43764Medicare UPIN
CO07079007Medicaid