Provider Demographics
NPI:1982700092
Name:JENNINGS, WILLARD DENNIS (PA-C)
Entity Type:Individual
Prefix:
First Name:WILLARD
Middle Name:DENNIS
Last Name:JENNINGS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 N CHURCH ST
Mailing Address - Street 2:STE 302
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-1439
Mailing Address - Country:US
Mailing Address - Phone:336-387-8100
Mailing Address - Fax:336-387-8202
Practice Address - Street 1:1002 N CHURCH ST
Practice Address - Street 2:STE 302
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1439
Practice Address - Country:US
Practice Address - Phone:336-387-8100
Practice Address - Fax:336-387-8202
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC100582363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCR40349Medicare UPIN