Provider Demographics
NPI:1356675912
Name:WILLARDSON, CRISSI LEIANN (PA-C)
Entity type:Individual
Prefix:
First Name:CRISSI
Middle Name:LEIANN
Last Name:WILLARDSON
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:CRISSI
Other - Middle Name:LEIANN
Other - Last Name:MAGLEBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:3895 W 7800 S STE 100
Mailing Address - Street 2:
Mailing Address - City:WEST JORDAN
Mailing Address - State:UT
Mailing Address - Zip Code:84088-5616
Mailing Address - Country:US
Mailing Address - Phone:801-309-6048
Mailing Address - Fax:801-748-2790
Practice Address - Street 1:3895 W 7800 S STE 100
Practice Address - Street 2:
Practice Address - City:WEST JORDAN
Practice Address - State:UT
Practice Address - Zip Code:84088-5616
Practice Address - Country:US
Practice Address - Phone:801-309-6048
Practice Address - Fax:801-748-2790
Is Sole Proprietor?:No
Enumeration Date:2009-09-29
Last Update Date:2019-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ4496363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant