Provider Demographics
NPI:1346228822
Name:WILLIAMS, REGINA (PA)
Entity type:Individual
Prefix:MISS
First Name:REGINA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 W RAND RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-1151
Mailing Address - Country:US
Mailing Address - Phone:847-618-5400
Mailing Address - Fax:847-618-3709
Practice Address - Street 1:199 W RAND RD
Practice Address - Street 2:
Practice Address - City:MOUNT PROSPECT
Practice Address - State:IL
Practice Address - Zip Code:60056-1151
Practice Address - Country:US
Practice Address - Phone:847-618-5400
Practice Address - Fax:847-618-3709
Is Sole Proprietor?:No
Enumeration Date:2006-01-05
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1026417363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL085000591OtherSTATE LICENSE
K23444Medicare ID - Type Unspecified