Provider Demographics
NPI:1013951417
Name:WILLIAMS, TANISHA G (PA)
Entity Type:Individual
Prefix:MS
First Name:TANISHA
Middle Name:G
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2673
Mailing Address - Fax:510-879-9059
Practice Address - Street 1:1805 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92411-1217
Practice Address - Country:US
Practice Address - Phone:909-887-6333
Practice Address - Fax:909-887-1985
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15707363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant