Provider Demographics
NPI:1174139182
Name:WILLIAMS, MICHAEL DAVID (NP-C)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:WILLIAMS
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6077 PRIMACY PKWY STE 140
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-5754
Mailing Address - Country:US
Mailing Address - Phone:901-259-1673
Mailing Address - Fax:901-259-7637
Practice Address - Street 1:7900 AIRWAYS BLVD BLDG B102
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-4118
Practice Address - Country:US
Practice Address - Phone:662-349-9023
Practice Address - Fax:662-349-9023
Is Sole Proprietor?:No
Enumeration Date:2020-09-16
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28243363L00000X
MSWILL-45YJ7O363LF0000X
TN211443363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN28243OtherSTATE LICENSE
MS904159OtherSTATE LICENSE
MS800828771OtherDRIVER'S LICENSE