Provider Demographics
NPI:1629031984
Name:WILLIAMS, STACY JO (PA-C)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:JO
Last Name:WILLIAMS
Suffix:
Gender:F
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 1:5601 J ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3948
Mailing Address - Country:US
Mailing Address - Phone:916-454-5922
Mailing Address - Fax:
Practice Address - Street 1:5601 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3948
Practice Address - Country:US
Practice Address - Phone:916-454-5922
Practice Address - Fax:916-454-2156
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2014-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04348363A00000X
CAPA19518363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8N8996OtherBLUE SHIELD
TXP00269387OtherRR/MEDICARE
TXQ39835Medicare UPIN
TXP00269387OtherRR/MEDICARE