Provider Demographics
NPI:1740261080
Name:WILLIAMS, KRISSI J (PA C)
Entity type:Individual
Prefix:MS
First Name:KRISSI
Middle Name:J
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA C
Other - Prefix:
Other - First Name:SUNNY
Other - Middle Name:CARE
Other - Last Name:CLINIC
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1187 DUCK RD STE 10
Mailing Address - Street 2:
Mailing Address - City:DUCK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-4570
Mailing Address - Country:US
Mailing Address - Phone:252-429-7200
Mailing Address - Fax:252-715-3678
Practice Address - Street 1:1187 DUCK RD STE 10
Practice Address - Street 2:
Practice Address - City:DUCK
Practice Address - State:NC
Practice Address - Zip Code:27949-4570
Practice Address - Country:US
Practice Address - Phone:252-429-7200
Practice Address - Fax:252-423-4588
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC104065363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110005998OtherLICENSE
NC104065OtherMEDICAL LICENSE