Provider Demographics
NPI:1396141974
Name:WILLIAMS, JOHN RICHARD I (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:RICHARD
Last Name:WILLIAMS
Suffix:I
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:189 BO JAMES ST STE 105
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:GA
Mailing Address - Zip Code:30525-6199
Mailing Address - Country:US
Mailing Address - Phone:706-782-0016
Mailing Address - Fax:706-782-0180
Practice Address - Street 1:189 BO JAMES ST STE 105
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:GA
Practice Address - Zip Code:30525-6199
Practice Address - Country:US
Practice Address - Phone:706-782-0016
Practice Address - Fax:706-782-0180
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
NC0010-13479363A00000X
GA007425363AS0400X
GA7425363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003153646HMedicaid
GA003153646KMedicaid
GA06705493OtherAMERIGROUP
GA1819077OtherWELLCARE
GA003153646IMedicaid
GA003153646GMedicaid
GA003153646JMedicaid
GA003153646LMedicaid