Provider Demographics
NPI:1790727915
Name:WILLIAMS, DEWAYNE R (CRNA)
Entity Type:Individual
Prefix:
First Name:DEWAYNE
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1050 DELAWARE AVE
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:OH
Mailing Address - Zip Code:43302-6416
Mailing Address - Country:US
Mailing Address - Phone:740-383-7778
Mailing Address - Fax:
Practice Address - Street 1:1050 DELAWARE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:OH
Practice Address - Zip Code:43302-6416
Practice Address - Country:US
Practice Address - Phone:740-383-7778
Practice Address - Fax:740-383-7942
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2014-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNA08622367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2638391Medicaid
OH2638391Medicaid