1962618843 NPI number — KEITH V WILLIAMSON PHYSICIAN ASSISTANT

Table of content: KEITH V WILLIAMSON PHYSICIAN ASSISTANT (NPI 1962618843)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962618843 NPI number — KEITH V WILLIAMSON PHYSICIAN ASSISTANT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIAMSON
Provider First Name:
KEITH
Provider Middle Name:
V
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PHYSICIAN ASSISTANT
Provider Gender Code:
M

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:
1962618843
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/27/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
535 E 70TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW YORK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10021-4872
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
212-606-1909
Provider Business Mailing Address Fax Number:
212-879-6526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
535 E 70TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10021-4872
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-606-1909
Provider Business Practice Location Address Fax Number:
212-879-6526
Provider Enumeration Date:
05/15/2007

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: 363AS0400X , with the licence number:  007912 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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