Provider Demographics
NPI:1265592885
Name:WILLIAMS, MATILDA KATHERINE (PA - C)
Entity type:Individual
Prefix:
First Name:MATILDA
Middle Name:KATHERINE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA - C
Other - Prefix:
Other - First Name:M.
Other - Middle Name:KAY
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:1021 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:SEMINOLE
Mailing Address - State:OK
Mailing Address - Zip Code:74868-2915
Mailing Address - Country:US
Mailing Address - Phone:405-382-5723
Mailing Address - Fax:
Practice Address - Street 1:619 NW 23RD ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-1415
Practice Address - Country:US
Practice Address - Phone:405-528-0221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OKPA629363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKR10977Medicare UPIN