Provider Demographics
NPI:1558078360
Name:WILLIAMS, DESTINY (PA-S)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W TERRELL AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2829
Mailing Address - Country:US
Mailing Address - Phone:817-250-7247
Mailing Address - Fax:
Practice Address - Street 1:1300 W TERRELL AVE STE 400
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2829
Practice Address - Country:US
Practice Address - Phone:817-250-7247
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
TXPA18143363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant