Provider Demographics
NPI:1497597306
Name:WILLIAMS, MARIAH A
Entity type:Individual
Prefix:
First Name:MARIAH
Middle Name:A
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:12411-5016
Mailing Address - Country:US
Mailing Address - Phone:845-901-9389
Mailing Address - Fax:
Practice Address - Street 1:246 W SWANNANOA AVE
Practice Address - Street 2:
Practice Address - City:LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:27298-3214
Practice Address - Country:US
Practice Address - Phone:336-795-2016
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-06-11
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-14484363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant