Provider Demographics
NPI:1972166114
Name:WILLIAMSON, DARTHVADER DEVON (RSA)
Entity Type:Individual
Prefix:
First Name:DARTHVADER
Middle Name:DEVON
Last Name:WILLIAMSON
Suffix:
Gender:M
Credentials:RSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13560 HIGHWAY 196
Mailing Address - Street 2:
Mailing Address - City:EADS
Mailing Address - State:TN
Mailing Address - Zip Code:38028-3606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2986 KATE BOND RD
Practice Address - Street 2:
Practice Address - City:BARTLETT
Practice Address - State:TN
Practice Address - Zip Code:38133-4003
Practice Address - Country:US
Practice Address - Phone:901-820-7468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-14
Last Update Date:2019-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMAS0000000047246ZC0007X
246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant