Provider Demographics
NPI:1720111651
Name:WILLIAMS, BARRY M (PA-C)
Entity type:Individual
Prefix:
First Name:BARRY
Middle Name:M
Last Name:WILLIAMS
Suffix:
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 1:280 PASADENA DR
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-2925
Mailing Address - Country:US
Mailing Address - Phone:859-278-1316
Mailing Address - Fax:859-276-3847
Practice Address - Street 1:2416 REGENCY ROAD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2954
Practice Address - Country:US
Practice Address - Phone:859-278-1316
Practice Address - Fax:859-276-3847
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2017-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA181363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002374Medicaid
KY95002374Medicaid
KY0169Medicare PIN