Provider Demographics
NPI:1356314843
Name:WILLES, JEREMY DAVID (PAC)
Entity Type:Individual
Prefix:
First Name:JEREMY
Middle Name:DAVID
Last Name:WILLES
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:260 FALLS AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-3370
Mailing Address - Country:US
Mailing Address - Phone:208-736-7422
Mailing Address - Fax:208-736-8905
Practice Address - Street 1:260 FALLS AVE
Practice Address - Street 2:SUITE C
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-3370
Practice Address - Country:US
Practice Address - Phone:208-736-7422
Practice Address - Fax:208-736-8905
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2013-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA638363A00000X
NVPA882363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000010161378OtherBLUE SHIELD
ID807683300Medicaid
ID807683301Medicaid
IDPAE68OtherBLUE CROSS
ID000010161377OtherBLUE SHIELD
NV100504125Medicaid
IDPAE69OtherBLUE CROSS
NV100035Medicare ID - Type Unspecified
NV100504125Medicaid