Provider Demographics
NPI:1699856344
Name:WILLIAMS, STEPHEN M (PAC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:M
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:PAC
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 447
Mailing Address - Street 2:
Mailing Address - City:GOODING
Mailing Address - State:ID
Mailing Address - Zip Code:83330
Mailing Address - Country:US
Mailing Address - Phone:208-934-5900
Mailing Address - Fax:208-934-5719
Practice Address - Street 1:425 IDAHO STREET
Practice Address - Street 2:
Practice Address - City:GOODING
Practice Address - State:ID
Practice Address - Zip Code:83330
Practice Address - Country:US
Practice Address - Phone:208-934-5900
Practice Address - Fax:208-934-5719
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA628363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant