Provider Demographics
NPI:1235308446
Name:WILLIAMS, MARY ALISON (PA-C)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ALISON
Last Name:WILLIAMS
Suffix:
Gender:F
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 1:755 MOUNT VERNON HWY
Mailing Address - Street 2:SUITE 110
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30328-4274
Mailing Address - Country:US
Mailing Address - Phone:404-256-5611
Mailing Address - Fax:404-256-9404
Practice Address - Street 1:755 MOUNT VERNON HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30328-4274
Practice Address - Country:US
Practice Address - Phone:404-256-5611
Practice Address - Fax:404-256-9404
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA004443363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA97WCGDPMedicare PIN
GAQ31753Medicare UPIN