Provider Demographics
NPI:1285671446
Name:WILLIAMS, JUSTIN D (CRNA)
Entity type:Individual
Prefix:MR
First Name:JUSTIN
Middle Name:D
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1485 S HIGHWAY 40
Mailing Address - Street 2:
Mailing Address - City:HEBER CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84032-3522
Mailing Address - Country:US
Mailing Address - Phone:435-654-2500
Mailing Address - Fax:
Practice Address - Street 1:650 E 250 S
Practice Address - Street 2:
Practice Address - City:HEBER CITY
Practice Address - State:UT
Practice Address - Zip Code:84032-2149
Practice Address - Country:US
Practice Address - Phone:435-671-0031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO074792367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO911387900Medicaid
MO831820171Medicare ID - Type UnspecifiedMEDICARE BC BS ARKANSAS