Provider Demographics
NPI:1861462061
Name:WILLIAMS, NYSA R (PT)
Entity Type:Individual
Prefix:MRS
First Name:NYSA
Middle Name:R
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 AVENIDA CABRILLO STE C
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5509
Mailing Address - Country:US
Mailing Address - Phone:800-943-3651
Mailing Address - Fax:
Practice Address - Street 1:130 AVENIDA CABRILLO STE C
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-5509
Practice Address - Country:US
Practice Address - Phone:800-943-3651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT33616225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO94223327Medicaid
CO803909Medicare ID - Type Unspecified