Provider Demographics
NPI:1003855776
Name:WILLIS, AARON MICHAEL (DPT)
Entity Type:Individual
Prefix:
First Name:AARON
Middle Name:MICHAEL
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13163 FOUNTAIN PARK DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:PLAYA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:90094-2040
Mailing Address - Country:US
Mailing Address - Phone:310-823-2220
Mailing Address - Fax:310-823-2636
Practice Address - Street 1:13163 FOUNTAIN PARK DR
Practice Address - Street 2:SUITE A
Practice Address - City:PLAYA VISTA
Practice Address - State:CA
Practice Address - Zip Code:90094-2040
Practice Address - Country:US
Practice Address - Phone:310-823-2220
Practice Address - Fax:310-823-2636
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA254682251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT25468AMedicare PIN