Provider Demographics
NPI:1477590958
Name:WILLIS, NEELIE BERLIN (PA-C)
Entity Type:Individual
Prefix:
First Name:NEELIE
Middle Name:BERLIN
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:NEELIE
Other - Middle Name:
Other - Last Name:BERLIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 31001-3306
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91110-3306
Mailing Address - Country:US
Mailing Address - Phone:208-734-5555
Mailing Address - Fax:208-734-4790
Practice Address - Street 1:526 SHOUP AVE W
Practice Address - Street 2:SUITE A
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-5050
Practice Address - Country:US
Practice Address - Phone:208-734-5555
Practice Address - Fax:208-734-4790
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPA-275363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant