Provider Demographics
NPI:1821548140
Name:WILLIAMSON, AVERY DANIELLE (PA-C)
Entity Type:Individual
Prefix:
First Name:AVERY
Middle Name:DANIELLE
Last Name:WILLIAMSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:AVERY
Other - Middle Name:DANIELLE
Other - Last Name:CERO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:7 DOCK HILL RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17842-8910
Mailing Address - Country:US
Mailing Address - Phone:570-837-2123
Mailing Address - Fax:570-837-2185
Practice Address - Street 1:145 SHAFFER ST
Practice Address - Street 2:
Practice Address - City:WILLIAMSPORT
Practice Address - State:PA
Practice Address - Zip Code:17702-6727
Practice Address - Country:US
Practice Address - Phone:570-327-1335
Practice Address - Fax:570-321-7800
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-11
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOA003982363A00000X
PAMA058611363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1032346410001Medicaid
PA1032346410001Medicaid