Provider Demographics
NPI:1861435679
Name:NIEMEYER, WILLIAM HENRY III (PA-C)
Entity type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:HENRY
Last Name:NIEMEYER
Suffix:III
Gender:M
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 1:1832 ASHLEY DRIVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:IL
Mailing Address - Zip Code:61920
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:385 W MAIN ST
Practice Address - Street 2:
Practice Address - City:AVON
Practice Address - State:CT
Practice Address - Zip Code:06001-4357
Practice Address - Country:US
Practice Address - Phone:860-777-1280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA01134363A00000X
CT004173363A00000X
IL085-001528363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004173OtherCT LIC
ILK22354Medicare ID - Type Unspecified