Provider Demographics
NPI:1679234959
Name:WILLIAMS, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 NAUTICAL WAY
Mailing Address - Street 2:
Mailing Address - City:SOUTH DENNIS
Mailing Address - State:MA
Mailing Address - Zip Code:02660-3780
Mailing Address - Country:US
Mailing Address - Phone:774-268-1293
Mailing Address - Fax:
Practice Address - Street 1:40 NORTH ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-3808
Practice Address - Country:US
Practice Address - Phone:508-862-2639
Practice Address - Fax:508-862-2693
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MACHW00533172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker