Healthcare Provider Details

I. General information

NPI: 1639215932
Provider Name (Legal Business Name): WILLARD ABE ANDES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1615 DELAWARE ST
LONGVIEW WA
98632-2367
US

IV. Provider business mailing address

403 S AMERICA ST
COVINGTON LA
70433-3531
US

V. Phone/Fax

Practice location:
  • Phone: 360-414-7878
  • Fax: 360-414-7876
Mailing address:
  • Phone: 919-610-9606
  • Fax: 958-276-4402

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD61081628
License Number StateWA
# 2
Primary TaxonomyN
Taxonomy Code207RH0000X
TaxonomyHematology (Internal Medicine) Physician
License NumberMD61081628
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number35830
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code207RX0202X
TaxonomyMedical Oncology Physician
License NumberMD61081628
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: