Provider Demographics
NPI:1578966073
Name:WILLIAMS, MATTHEW R (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1616 N MAIN ST
Mailing Address - Street 2:STE 100A
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-4473
Mailing Address - Country:US
Mailing Address - Phone:276-783-9752
Mailing Address - Fax:276-783-7786
Practice Address - Street 1:1616 N MAIN ST
Practice Address - Street 2:STE 100A
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-4473
Practice Address - Country:US
Practice Address - Phone:276-783-9752
Practice Address - Fax:276-783-7786
Is Sole Proprietor?:No
Enumeration Date:2014-09-29
Last Update Date:2017-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN2614363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ008775Medicaid
TNQ008775Medicaid
0677340002Medicare NSC
0677340001Medicare NSC
0677340004Medicare NSC
TN3376148Medicare PIN
TN3376146Medicare PIN