Provider Demographics
NPI:1750826269
Name:WILLIAMS, ROBERT WADE
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WADE
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 1:7769 VALLEY OAK DR
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6573
Mailing Address - Country:US
Mailing Address - Phone:443-825-8538
Mailing Address - Fax:
Practice Address - Street 1:3300 CENTENNIAL LN
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-3600
Practice Address - Country:US
Practice Address - Phone:410-750-9439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-20
Last Update Date:2020-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0006310363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant