Provider Demographics
NPI:1023202744
Name:WILLIS, MONIQUE ANTOINETTE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:MONIQUE
Middle Name:ANTOINETTE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3500 W MANCHESTER BLVD UNIT 23
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90305-4023
Mailing Address - Country:US
Mailing Address - Phone:310-412-4123
Mailing Address - Fax:310-419-7279
Practice Address - Street 1:8930 S SEPULVEDA BLVD STE 210
Practice Address - Street 2:
Practice Address - City:WESTCHESTER
Practice Address - State:CA
Practice Address - Zip Code:90045-3624
Practice Address - Country:US
Practice Address - Phone:310-649-4800
Practice Address - Fax:310-649-1404
Is Sole Proprietor?:No
Enumeration Date:2007-09-06
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18478363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant