Provider Demographics
NPI:1295965788
Name:WILLIAMS, REGINA (PA)
Entity type:Individual
Prefix:
First Name:REGINA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:REGINA
Other - Middle Name:
Other - Last Name:PERSICO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1129 NORTHERN BLVD STE 408
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3022
Mailing Address - Country:US
Mailing Address - Phone:516-627-2121
Mailing Address - Fax:516-869-1386
Practice Address - Street 1:1129 NORTHERN BLVD STE 408
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3022
Practice Address - Country:US
Practice Address - Phone:516-627-2121
Practice Address - Fax:516-869-1386
Is Sole Proprietor?:No
Enumeration Date:2009-07-20
Last Update Date:2009-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY011736363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical