Provider Demographics
NPI:1720807084
Name:WILLIAMS, MARCUS OSHEA
Entity type:Individual
Prefix:
First Name:MARCUS
Middle Name:OSHEA
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2337 PENNSYLVANNIA AVE
Mailing Address - Street 2:
Mailing Address - City:HUNDRED
Mailing Address - State:WV
Mailing Address - Zip Code:26575
Mailing Address - Country:US
Mailing Address - Phone:860-840-4133
Mailing Address - Fax:
Practice Address - Street 1:2337 PENNSYLVANNIA AVE
Practice Address - Street 2:
Practice Address - City:HUNDRED
Practice Address - State:WV
Practice Address - Zip Code:26575
Practice Address - Country:US
Practice Address - Phone:860-840-4133
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1821206228Medicaid
WV1356607394Medicaid
WV125553494Medicaid