Provider Demographics
NPI:1255369765
Name:WILLIAMS, MARK D (PA-C)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:D
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1793 13TH ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-2541
Mailing Address - Country:US
Mailing Address - Phone:503-362-8385
Mailing Address - Fax:503-362-8435
Practice Address - Street 1:1793 13TH ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-2541
Practice Address - Country:US
Practice Address - Phone:503-362-8385
Practice Address - Fax:503-362-8435
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORPA00623363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR139952Medicare PIN
ORS86664Medicare UPIN