Healthcare Provider Details

I. General information

NPI: 1144766775
Provider Name (Legal Business Name): CHARLET WILLIS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2017
Last Update Date: 04/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 UNIVERSITY DR STE 1300
MARION OH
43302-1104
US

IV. Provider business mailing address

5400 FRANTZ RD STE 250
DUBLIN OH
43016-6102
US

V. Phone/Fax

Practice location:
  • Phone: 740-692-4440
  • Fax:
Mailing address:
  • Phone: 614-533-6497
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50.005954RX
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: