MEDICARE: DENISE BOYD WILLIS PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	0110001909	VA
2	363AM0700X	Medical Physician Assistant	0110001909	VA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0110001909	OTHER	VA	VA STATE MEDICAL LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326024076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DENISE BOYD WILLIS PA-C

Provider Business Mailing Address
First Line	:	3912 SCHOONER LANE
Second Line	:
City	:	HOPEWELL
State	:	VA
Zip	:	23860
Country	:	US
Telephone Number	:	804-892-3480
Fax Number	:

Provider Business Practice Location Address
First Line	:	5303 PLAZA DR
Second Line	:	SUITE 101
City	:	HOPEWELL
State	:	VA
Zip	:	23860-7331
Country	:	US
Telephone Number	:	804-458-2006
Fax Number	:	804-458-3629

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/15/2005
Last Update Date	:	06/04/2013

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