Provider Demographics
NPI:1659542926
Name:WILLIAMS, MARC A (PA)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N GRAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2729
Mailing Address - Country:US
Mailing Address - Phone:719-542-0072
Mailing Address - Fax:719-542-9888
Practice Address - Street 1:1600 N GRAND AVE STE 310
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2729
Practice Address - Country:US
Practice Address - Phone:719-542-0072
Practice Address - Fax:719-542-9888
Is Sole Proprietor?:No
Enumeration Date:2008-03-14
Last Update Date:2008-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1095363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical