Provider Demographics
NPI:1861510240
Name:WILLIS, KONNEEN (PA)
Entity Type:Individual
Prefix:MS
First Name:KONNEEN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1551 RENAISSANCE TOWNE DR
Mailing Address - Street 2:STE 540
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-7678
Mailing Address - Country:US
Mailing Address - Phone:801-408-7660
Mailing Address - Fax:801-408-7650
Practice Address - Street 1:1551 RENAISSANCE TOWNE DR
Practice Address - Street 2:STE 460
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-7667
Practice Address - Country:US
Practice Address - Phone:801-294-7246
Practice Address - Fax:801-294-2560
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT107354-1206363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1861510240Medicaid
UT000063838Medicare PIN
UT000060938Medicare PIN