Basic Information
| Provider Information | |||||||||
| NPI: | 1306827100 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | EARLE | ||||||||
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| Credential: | PA C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1233 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033787526 | ||||||||
| FaxNumber: | 5035854278 | ||||||||
| Practice Location | |||||||||
| Address1: | 1233 EDGEWATER ST NW | ||||||||
| Address2: | |||||||||
| City: | SALEM | ||||||||
| State: | OR | ||||||||
| PostalCode: | 973044049 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033787526 | ||||||||
| FaxNumber: | 5035854278 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2005 | ||||||||
| LastUpdateDate: | 04/07/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363AM0700X | PA00403 | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 023015 | 05 | OR | MEDICAID |