Provider Demographics
NPI:1790757771
Name:WILLIAMS, KORY LYNNE (PAC)
Entity Type:Individual
Prefix:
First Name:KORY
Middle Name:LYNNE
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 1:2 BURNETT COURT
Mailing Address - Street 2:STE 100
Mailing Address - City:DURANGO
Mailing Address - State:CO
Mailing Address - Zip Code:81301-3647
Mailing Address - Country:US
Mailing Address - Phone:970-385-4022
Mailing Address - Fax:970-385-4337
Practice Address - Street 1:2 BURNETT COURT
Practice Address - Street 2:STE 100
Practice Address - City:DURANGO
Practice Address - State:CO
Practice Address - Zip Code:81301-3647
Practice Address - Country:US
Practice Address - Phone:970-385-4022
Practice Address - Fax:970-385-4337
Is Sole Proprietor?:No
Enumeration Date:2006-02-03
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1544363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COS50460Medicare UPIN
CO803559Medicare ID - Type Unspecified