Basic Information
| Provider Information | |||||||||
| NPI: | 1558364083 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIAMS | ||||||||
| FirstName: | RICKEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7265 E TANQUE VERDE RD | ||||||||
| Address2: | STE 121 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207222585 | ||||||||
| FaxNumber: | 5207221097 | ||||||||
| Practice Location | |||||||||
| Address1: | 7265 E TANQUE VERDE RD | ||||||||
| Address2: | STE 121 | ||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857153467 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5207222585 | ||||||||
| FaxNumber: | 5207221097 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2005 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 14264 | AZ | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 238164-02 | 05 | AZ | MEDICAID |