Provider Demographics
NPI:1730870130
Name:WILLIAMSON, LATISHA
Entity type:Individual
Prefix:
First Name:LATISHA
Middle Name:
Last Name:WILLIAMSON
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 1:1187 NEWBERG CMNS
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92582-4299
Mailing Address - Country:US
Mailing Address - Phone:702-937-5694
Mailing Address - Fax:
Practice Address - Street 1:1187 NEWBERG CMNS
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92582-4299
Practice Address - Country:US
Practice Address - Phone:702-937-5694
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD07298637207ZC0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZC0006XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology