Provider Demographics
NPI:1962965772
Name:WILLIAMS, NATHAN EARL
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:EARL
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 1:3821 POINTE FOREST DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-1015
Mailing Address - Country:US
Mailing Address - Phone:314-831-3852
Mailing Address - Fax:
Practice Address - Street 1:3821 POINTE FOREST DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-1015
Practice Address - Country:US
Practice Address - Phone:314-831-3852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1306222146Medicaid