Provider Demographics
NPI:1669427738
Name:WILLIAMS, LESLIE A (AA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 15TH STREET, BI-2144
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30912
Mailing Address - Country:US
Mailing Address - Phone:706-721-3871
Mailing Address - Fax:706-721-7753
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:ROOM BI-2144
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-3871
Practice Address - Fax:706-721-7753
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2013-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA001976367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001975AMedicaid
GA100001975AMedicaid
GAR61531Medicare UPIN