Provider Demographics
NPI:1639894710
Name:WILLIAMS, GENA NICOLE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:GENA
Middle Name:NICOLE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:222 S BROAD MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:FRACKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17931-2202
Mailing Address - Country:US
Mailing Address - Phone:570-985-4318
Mailing Address - Fax:
Practice Address - Street 1:700 E NORWEGIAN ST
Practice Address - Street 2:
Practice Address - City:POTTSVILLE
Practice Address - State:PA
Practice Address - Zip Code:17901-2710
Practice Address - Country:US
Practice Address - Phone:570-621-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-11
Last Update Date:2023-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
PAMA064087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant