Provider Demographics
NPI:1184696759
Name:BRAZIL, WILLIAM W (PA)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:W
Last Name:BRAZIL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 MIMOSA DR
Mailing Address - Street 2:STE 1R
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31792-6678
Mailing Address - Country:US
Mailing Address - Phone:229-227-1690
Mailing Address - Fax:229-227-1829
Practice Address - Street 1:100 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6676
Practice Address - Country:US
Practice Address - Phone:229-226-9141
Practice Address - Fax:229-228-0637
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2019-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGA001990363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA302656OtherWELLCARE
GA100001302AMedicaid
GA100001302AOtherPEACH STATE
GA970009975OtherRAIL ROAD MEDICARE
GA97BBDZLMedicare PIN
GA100001302AMedicaid