Healthcare Provider Details

I. General information

NPI: 1437286671
Provider Name (Legal Business Name): AUTUMN CORINA WILLS P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2007
Last Update Date: 03/02/2021
Certification Date: 03/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 SAINT FRANCIS DR STE 32121
CAPE GIRARDEAU MO
63703-5049
US

IV. Provider business mailing address

PO BOX 801143
KANSAS CITY MO
64180-1143
US

V. Phone/Fax

Practice location:
  • Phone: 573-339-8718
  • Fax: 573-339-9543
Mailing address:
  • Phone: 573-331-5583
  • Fax: 573-331-5079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2018030948
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085002848
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: