Provider Demographics
NPI:1811013741
Name:WILLIAMS, TANYA L (PA)
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:L
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 601643
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1643
Mailing Address - Country:US
Mailing Address - Phone:704-667-3960
Mailing Address - Fax:704-667-3961
Practice Address - Street 1:10650 PARK ROAD
Practice Address - Street 2:SUITE 300
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-8543
Practice Address - Country:US
Practice Address - Phone:704-667-3960
Practice Address - Fax:704-667-3961
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2016-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-00333363A00000X
SC724363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC0954PAMedicaid
NC8102295Medicaid
NC1811013741Medicaid
NC2760013AMedicare PIN