Provider Demographics
NPI:1326024076
Name:WILLIS, DENISE BOYD (PA-C)
Entity Type:Individual
Prefix:
First Name:DENISE
Middle Name:BOYD
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 1:3912 SCHOONER LANE
Mailing Address - Street 2:
Mailing Address - City:HOPEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:23860
Mailing Address - Country:US
Mailing Address - Phone:804-892-3480
Mailing Address - Fax:
Practice Address - Street 1:5303 PLAZA DR
Practice Address - Street 2:SUITE 101
Practice Address - City:HOPEWELL
Practice Address - State:VA
Practice Address - Zip Code:23860-7331
Practice Address - Country:US
Practice Address - Phone:804-458-2006
Practice Address - Fax:804-458-3629
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2013-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001909207Q00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0110001909OtherVA STATE MEDICAL LICENSE
VA007691084Medicaid
VA007691084Medicaid
VAQ48919Medicare UPIN