Provider Demographics
NPI:1891039293
Name:WILLIAMS, JOHN ALBERT (PTA)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ALBERT
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 SPARKS ST N APT 11
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3753
Mailing Address - Country:US
Mailing Address - Phone:208-732-6134
Mailing Address - Fax:
Practice Address - Street 1:640 FILER AVE W
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4533
Practice Address - Country:US
Practice Address - Phone:208-734-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPTA-182225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant