Healthcare Provider Details

I. General information

NPI: 1023682986
Provider Name (Legal Business Name): AUSTIN JOE WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2021
Last Update Date: 05/16/2021
Certification Date: 05/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 CLUB DR
VALLEJO CA
94592-1187
US

IV. Provider business mailing address

3476 S LELAND ST
SAN PEDRO CA
90731-6126
US

V. Phone/Fax

Practice location:
  • Phone: 707-638-5809
  • Fax:
Mailing address:
  • Phone: 310-922-4637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: