Provider Demographics
NPI:1750478129
Name:WILLIAMS, CAROLYN MCCULLAGH (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:CAROLYN
Middle Name:MCCULLAGH
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 - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2699
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32513-2699
Mailing Address - Country:US
Mailing Address - Phone:850-475-4686
Mailing Address - Fax:850-475-4619
Practice Address - Street 1:3871 E HIGHWAY 98 STE 201
Practice Address - Street 2:
Practice Address - City:PORT ST JOE
Practice Address - State:FL
Practice Address - Zip Code:32456
Practice Address - Country:US
Practice Address - Phone:850-229-3712
Practice Address - Fax:850-229-3712
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2019-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA 9101182363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL291229500Medicaid
P68685Medicare ID - Type Unspecified
E7967AMedicare UPIN