Provider Demographics
NPI:1528033479
Name:WILLIS, JULIE A (PA-C)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
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 1:625 S NEW BALLAS RD
Mailing Address - Street 2:SUITE R-7040
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8232
Mailing Address - Country:US
Mailing Address - Phone:314-251-6970
Mailing Address - Fax:314-251-1053
Practice Address - Street 1:625 S NEW BALLAS RD
Practice Address - Street 2:SUITE R-7040
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6970
Practice Address - Fax:314-251-1053
Is Sole Proprietor?:No
Enumeration Date:2006-02-22
Last Update Date:2008-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001031727363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP45141Medicare UPIN