1750376083 NPI number — LISA WILLIAMS M.D.

Table of content: LISA WILLIAMS M.D. (NPI 1750376083)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750376083 NPI number — LISA WILLIAMS M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMS
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1750376083
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
P.O. BOX 1000
Provider Second Line Business Mailing Address:
1443 BECK AVENUE
Provider Business Mailing Address City Name:
CODY
Provider Business Mailing Address State Name:
WY
Provider Business Mailing Address Postal Code:
82414-3423
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
307-527-7811
Provider Business Mailing Address Fax Number:
307-527-7396

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1443 BECK AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CODY
Provider Business Practice Location Address State Name:
WY
Provider Business Practice Location Address Postal Code:
82414-3423
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
307-527-7811
Provider Business Practice Location Address Fax Number:
307-527-7396
Provider Enumeration Date:
09/13/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  6662A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 6662A , registered in the state of WY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 117167400 , issued by the state of ( WY ) . This identifiers is of the category "MEDICAID".