Provider Demographics
NPI:1326059692
Name:WILLEY, JAMES O'BRYAN (PA)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:O'BRYAN
Last Name:WILLEY
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3737 SOUTHERN BLVD STE 2100
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1285
Mailing Address - Country:US
Mailing Address - Phone:937-433-5309
Mailing Address - Fax:937-298-0287
Practice Address - Street 1:3737 SOUTHERN BLVD
Practice Address - Street 2:SUITE 2100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1225
Practice Address - Country:US
Practice Address - Phone:937-433-5309
Practice Address - Fax:937-298-0287
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50002155363A00000X
OH2155363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH349758OtherANTHEM
OHP00182934OtherMEDICARE RAILROAD
OHP00182934OtherMEDICARE ID
OHQ18601Medicare UPIN
OHPA23142Medicare ID - Type Unspecified
OHP00182934OtherMEDICARE ID