Provider Demographics
NPI:1982473039
Name:WILLIAMS, RONALD RAE JR
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:RAE
Last Name:WILLIAMS
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2455 W SERENE AVE UNIT 639
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89123-6539
Mailing Address - Country:US
Mailing Address - Phone:702-900-5515
Mailing Address - Fax:
Practice Address - Street 1:4040 S EASTERN AVE
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89119-0810
Practice Address - Country:US
Practice Address - Phone:702-463-0300
Practice Address - Fax:702-463-0301
Is Sole Proprietor?:No
Enumeration Date:2023-12-29
Last Update Date:2023-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN268505164W00000X
NV829628164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse