Provider Demographics
NPI:1790369403
Name:WILLIAMS, ADAM
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 NORTH MEDICAL DRIVE
Mailing Address - Street 2:3RD FLOOR SOUTH
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0001
Mailing Address - Country:US
Mailing Address - Phone:801-646-7128
Mailing Address - Fax:
Practice Address - Street 1:30 NORTH MEDICAL DRIVE
Practice Address - Street 2:3RD FLOOR SOUTH
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0001
Practice Address - Country:US
Practice Address - Phone:801-646-7128
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-09
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT13559362-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program