Provider Demographics
NPI:1235331802
Name:WILLIS, ROBERT (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
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 1:1240 GRASSLAND DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-8293
Mailing Address - Country:US
Mailing Address - Phone:208-528-0316
Mailing Address - Fax:
Practice Address - Street 1:3425 MERLIN DR
Practice Address - Street 2:SUITE 200
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7430
Practice Address - Country:US
Practice Address - Phone:208-528-6653
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2015-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-456363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical