Provider Demographics
NPI:1316207921
Name:WILLAERT, ABBY MARIE (PA-C)
Entity Type:Individual
Prefix:
First Name:ABBY
Middle Name:MARIE
Last Name:WILLAERT
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ABBY
Other - Middle Name:MARIE
Other - Last Name:SCHWALBACH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:640 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-2502
Mailing Address - Country:US
Mailing Address - Phone:651-254-3456
Mailing Address - Fax:651-254-5216
Practice Address - Street 1:640 JACKSON ST
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-2502
Practice Address - Country:US
Practice Address - Phone:651-254-3456
Practice Address - Fax:651-254-5216
Is Sole Proprietor?:No
Enumeration Date:2012-05-17
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1716363A00000X
WI3071-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant