Provider Demographics
NPI:1679652010
Name:WILLIAMS, JENNIFER L (PAC)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 W YELLOWSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8723
Mailing Address - Country:US
Mailing Address - Phone:307-527-7129
Mailing Address - Fax:307-587-7394
Practice Address - Street 1:201 YELLOWSTONE AVE
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-9313
Practice Address - Country:US
Practice Address - Phone:307-527-7561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY314481OtherBCBS PIN
WY108527100OtherWY MDCD PIN
WY925161030924OtherPREFERRED ONE PIN
WY970019845Medicare PIN
WYW310921Medicare PIN
WY1153260002Medicare PIN
WY925161030924OtherPREFERRED ONE PIN