Provider Demographics
NPI:1508992140
Name:WILLIAMS, SCOTT A (RN, CNS, APN)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:RN, CNS, APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 S PARK AVE
Mailing Address - Street 2:
Mailing Address - City:RENSSELAER
Mailing Address - State:IN
Mailing Address - Zip Code:47978-3040
Mailing Address - Country:US
Mailing Address - Phone:219-866-8478
Mailing Address - Fax:
Practice Address - Street 1:123 S MCKINLEY AVE
Practice Address - Street 2:
Practice Address - City:RENSSELAER
Practice Address - State:IN
Practice Address - Zip Code:47978-2949
Practice Address - Country:US
Practice Address - Phone:219-866-7555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN#28121997A364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN222410Medicare PIN