Provider Demographics
NPI:1306150933
Name:WILLIAMS, STEPHEN CORY
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:CORY
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7687
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65205-7687
Mailing Address - Country:US
Mailing Address - Phone:573-882-2259
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:3W27
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-5276
Practice Address - Country:US
Practice Address - Phone:573-882-2568
Practice Address - Fax:573-882-2226
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-06
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2011001349367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO152360431Medicare PIN