Provider Demographics
NPI:1831149194
Name:WILLIS, JOHN J (PA-C)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:J
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:2158 ACACIA AVE
Mailing Address - Street 2:
Mailing Address - City:SUTTER
Mailing Address - State:CA
Mailing Address - Zip Code:95982-2508
Mailing Address - Country:US
Mailing Address - Phone:415-265-0268
Mailing Address - Fax:530-755-3219
Practice Address - Street 1:1429 COLUSA HWY
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95993-9092
Practice Address - Country:US
Practice Address - Phone:530-674-7000
Practice Address - Fax:530-755-3219
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA13636363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA136360Medicare ID - Type Unspecified
CAS99183Medicare UPIN