Provider Demographics
NPI:1497846091
Name:WILLIS, CHARLA RAE (MD)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:RAE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CHARLA
Other - Middle Name:RAE
Other - Last Name:NEAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-746-6348
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2016-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9369207R00000X
WAMD00045264207R00000X
CT033594207R00000X
MDD0056472207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1011897Medicaid
ID74930OtherBLUE CROSS
ID1131387OtherDMERC
WA0222531OtherLABOR & INDUSTRIES
ID1497846091OtherREGENCE BLUESHIELD
ID1497846091Medicaid
WA8855833Medicare PIN
ID1131387Medicare PIN
ID1131387OtherDMERC
IDF76844Medicare UPIN