Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | O-157 | ID |
Y | 207QS0010X | Family Doctor - Sports Medicine | O-157 | ID |
NPI | 1114961166 |
---|---|
Provider Name | Dr. Mark Scott Williams |
First Address | Nampa, ID 83686-6011 |
Second Address | Nampa, ID 83686-6011 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 16/06/2006 |
Last Update Date | 30/09/2014 |