Provider Demographics
NPI:1467691402
Name:WILLIS, PAULA SUZANNE (PA-C)
Entity Type:Individual
Prefix:MISS
First Name:PAULA
Middle Name:SUZANNE
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 1:14089 ABERCORN ST
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31419-1966
Mailing Address - Country:US
Mailing Address - Phone:912-350-2121
Mailing Address - Fax:912-350-2145
Practice Address - Street 1:14089 ABERCORN ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31419-1966
Practice Address - Country:US
Practice Address - Phone:912-350-2121
Practice Address - Fax:912-350-2145
Is Sole Proprietor?:No
Enumeration Date:2009-02-16
Last Update Date:2014-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003144363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003121625EMedicaid
GA003121625BMedicaid
GA003121625DMedicaid
GA003121625AMedicaid
GAP01110461OtherRAILROAD MEDICARE
GA003121625CMedicaid
GAP01036869OtherRAILROAD MEDICARE
GA003121625EMedicaid
GA202I974485Medicare PIN
GA003121625CMedicaid