Provider Demographics
NPI:1902201171
Name:WILLIS, CHRISTINE ELAINE (PA-C)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:ELAINE
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:ELAINE
Other - Last Name:GONEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1162 CYPRESS GLEN CIR
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-7560
Mailing Address - Country:US
Mailing Address - Phone:407-343-9006
Mailing Address - Fax:407-343-0999
Practice Address - Street 1:1162 CYPRESS GLEN CIR
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-7560
Practice Address - Country:US
Practice Address - Phone:407-343-9006
Practice Address - Fax:407-343-0999
Is Sole Proprietor?:No
Enumeration Date:2014-10-29
Last Update Date:2014-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108176363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical