Provider Demographics
NPI:1548558950
Name:WILLIAMS, NICKOLAS A (PA-C)
Entity Type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:A
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 1:1005 HEALTH CENTER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:MATTOON
Mailing Address - State:IL
Mailing Address - Zip Code:61938-4653
Mailing Address - Country:US
Mailing Address - Phone:217-868-2812
Mailing Address - Fax:217-258-2216
Practice Address - Street 1:1303 W EVERGREEN AVE STE 200
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-1638
Practice Address - Country:US
Practice Address - Phone:217-342-3400
Practice Address - Fax:217-342-3477
Is Sole Proprietor?:No
Enumeration Date:2011-07-19
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085004069363A00000X, 363AS0400X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant