Provider Demographics
NPI:1326044587
Name:WILLIS, CHRISTIANNE M (PA)
Entity Type:Individual
Prefix:
First Name:CHRISTIANNE
Middle Name:M
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:CHRISTIANNE
Other - Middle Name:M
Other - Last Name:KUENNEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA
Mailing Address - Street 1:1500 ASSOCIATES DR
Mailing Address - Street 2:
Mailing Address - City:DUBUQUE
Mailing Address - State:IA
Mailing Address - Zip Code:52002-2201
Mailing Address - Country:US
Mailing Address - Phone:563-584-4100
Mailing Address - Fax:563-584-4110
Practice Address - Street 1:117 S MADISON ST
Practice Address - Street 2:
Practice Address - City:CUBA CITY
Practice Address - State:WI
Practice Address - Zip Code:53807-1154
Practice Address - Country:US
Practice Address - Phone:608-744-2115
Practice Address - Fax:608-744-2117
Is Sole Proprietor?:No
Enumeration Date:2005-06-22
Last Update Date:2009-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA1391363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI41957800Medicaid
WI41957800Medicaid
IAI15706Medicare PIN