Provider Demographics
NPI:1801978218
Name:WILLIS, JEFFREY A (PA)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:A
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 HAGEN DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14625-2658
Mailing Address - Country:US
Mailing Address - Phone:585-338-2700
Mailing Address - Fax:
Practice Address - Street 1:30 HAGEN DR
Practice Address - Street 2:SUITE 100
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14625-2658
Practice Address - Country:US
Practice Address - Phone:585-338-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2021-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010727363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
000929329001OtherHEALTHNOW
929329001OtherCOMMUNITY BLUE
PA0498OtherPREFERRED CARE
PO19010727OtherBLUE CHOICE
929329001OtherCOMMUNITY BLUE
Q52339Medicare UPIN