Healthcare Provider Details

I. General information

NPI: 1225650450
Provider Name (Legal Business Name): WILLOW BARTHOLOMEW PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WILLOW HUBBARD PA

II. Dates (important events)

Enumeration Date: 05/11/2020
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 SOUTH ST
FORT BRAGG CA
95437-5540
US

IV. Provider business mailing address

710 RHODODENDRON AVE
BLACK MOUNTAIN NC
28711-2934
US

V. Phone/Fax

Practice location:
  • Phone: 707-964-1251
  • Fax: 707-961-2722
Mailing address:
  • Phone: 828-989-1691
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number59339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: