Provider Demographics
NPI:1780867473
Name:WILLIS, JERAMY C (KCSA)
Entity Type:Individual
Prefix:MR
First Name:JERAMY
Middle Name:C
Last Name:WILLIS
Suffix:
Gender:M
Credentials:KCSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1945 SCOTTSVILLE RD. B2 PMB 397
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42104
Mailing Address - Country:US
Mailing Address - Phone:270-781-4828
Mailing Address - Fax:270-781-4828
Practice Address - Street 1:1945 SCOTTSVILLE RD
Practice Address - Street 2:B2 PMB 397
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42104-3376
Practice Address - Country:US
Practice Address - Phone:270-781-4828
Practice Address - Fax:270-781-4828
Is Sole Proprietor?:No
Enumeration Date:2007-12-17
Last Update Date:2007-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYSA164363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical