Provider Demographics
NPI:1073618260
Name:WILLIS, RANDEE DENICE (PA-C)
Entity Type:Individual
Prefix:MS
First Name:RANDEE
Middle Name:DENICE
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 1:24209 PARK ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-6554
Mailing Address - Country:US
Mailing Address - Phone:310-373-5022
Mailing Address - Fax:
Practice Address - Street 1:23456 HAWTHORNE BLVD STE 100
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-4752
Practice Address - Country:US
Practice Address - Phone:310-540-5272
Practice Address - Fax:310-540-7271
Is Sole Proprietor?:No
Enumeration Date:2006-09-13
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13139PA363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13139PAOtherSTATE LICENSE NUMBER
CAP03946Medicare ID - Type Unspecified