Provider Demographics
NPI:1770952095
Name:WILLIAMS, MARA LEONE (PA-C)
Entity type:Individual
Prefix:
First Name:MARA
Middle Name:LEONE
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2840 INDEX RD
Mailing Address - Street 2:
Mailing Address - City:FITCHBURG
Mailing Address - State:WI
Mailing Address - Zip Code:53713-3117
Mailing Address - Country:US
Mailing Address - Phone:608-440-1682
Mailing Address - Fax:
Practice Address - Street 1:8025 EXCELSIOR DR
Practice Address - Street 2:#110
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53717-1900
Practice Address - Country:US
Practice Address - Phone:608-663-6154
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
WI5858363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist