Provider Demographics
NPI:1528624160
Name:WILLIAMS, RAVEN SHANISE (PA-C)
Entity type:Individual
Prefix:
First Name:RAVEN
Middle Name:SHANISE
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 1:702 MARTIN LUTHER KING ST
Mailing Address - Street 2:
Mailing Address - City:MOUND BAYOU
Mailing Address - State:MS
Mailing Address - Zip Code:38762-9314
Mailing Address - Country:US
Mailing Address - Phone:662-741-8800
Mailing Address - Fax:
Practice Address - Street 1:702 W. M.L.K. JR DR.
Practice Address - Street 2:
Practice Address - City:MOUND BAYOU
Practice Address - State:MS
Practice Address - Zip Code:38762
Practice Address - Country:US
Practice Address - Phone:662-741-2151
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-18
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6260363A00000X
AZ8040363A00000X
MSPA00656363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant