Provider Demographics
NPI:1134663834
Name:WILLIS, AUDRIANA K (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDRIANA
Middle Name:K
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 1:702 NEWMAN RD
Mailing Address - Street 2:
Mailing Address - City:NEW BERN
Mailing Address - State:NC
Mailing Address - Zip Code:28562-5238
Mailing Address - Country:US
Mailing Address - Phone:252-633-5333
Mailing Address - Fax:252-633-9443
Practice Address - Street 1:702 NEWMAN RD
Practice Address - Street 2:
Practice Address - City:NEW BERN
Practice Address - State:NC
Practice Address - Zip Code:28562-5238
Practice Address - Country:US
Practice Address - Phone:252-633-5333
Practice Address - Fax:252-633-9443
Is Sole Proprietor?:No
Enumeration Date:2016-12-14
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-06955363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant