Provider Demographics
NPI:1396079042
Name:WILLIAMS, GREG LEE (NP)
Entity type:Individual
Prefix:
First Name:GREG
Middle Name:LEE
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:388 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAXLEY
Mailing Address - State:GA
Mailing Address - Zip Code:31513-0104
Mailing Address - Country:US
Mailing Address - Phone:912-705-9680
Mailing Address - Fax:912-705-0531
Practice Address - Street 1:388 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BAXLEY
Practice Address - State:GA
Practice Address - Zip Code:31513-0104
Practice Address - Country:US
Practice Address - Phone:912-705-9680
Practice Address - Fax:912-705-0531
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-29
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN147732363L00000X
GARN147732NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G704612OtherMEDICARE PTAN
GA812644415JMedicaid
GA003120968AMedicaid