Provider Demographics
NPI:1821253683
Name:WILLIAMS, JONATHAN KEITH (NP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:KEITH
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 WASHINGTON PARKWAY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-523-1122
Mailing Address - Fax:208-523-2582
Practice Address - Street 1:3910 WASHINGTON PARKWAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7596
Practice Address - Country:US
Practice Address - Phone:208-523-1122
Practice Address - Fax:208-523-2582
Is Sole Proprietor?:No
Enumeration Date:2008-07-22
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-871A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1821253683Medicaid