Provider Demographics
NPI:1598879884
Name:WILLIS, MICHELLE L (PA-C)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:L
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 1:939 W BELLE PLAINE AVE
Mailing Address - Street 2:#3
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60613-2168
Mailing Address - Country:US
Mailing Address - Phone:630-418-3148
Mailing Address - Fax:
Practice Address - Street 1:2701 W 68TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60629-1813
Practice Address - Country:US
Practice Address - Phone:773-884-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2017-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085.001333363A00000X
CAPA22806363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P23238Medicare UPIN
IL203876004Medicare PIN
214834004Medicare PIN