Provider Demographics
NPI:1568632297
Name:WILLIAMS, GREGORY ERIC (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:ERIC
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 742616
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2616
Mailing Address - Country:US
Mailing Address - Phone:770-219-8420
Mailing Address - Fax:
Practice Address - Street 1:73 MAXWELL LN
Practice Address - Street 2:
Practice Address - City:DAHLONEGA
Practice Address - State:GA
Practice Address - Zip Code:30533-7146
Practice Address - Country:US
Practice Address - Phone:770-219-9630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA005267363A00000X
GA5267363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA286183752CMedicaid
GA286183752BMedicaid
GA286183752CMedicaid