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General NPI Number Information
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NPI Number | 1356314843
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Entity Type | Individual
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Provider Name | JEREMY DAVID WILLES PAC
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Gender | Male
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Dates
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Enumeration Date | 02/07/2006
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Last Update Date | 05/08/2013
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Provider Practice Location Address
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Address Line | 260 FALLS AVE SUITE C
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City | TWIN FALLS
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State | ID
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Zip | 83301-3370
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Country | US
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Telephone | 208-736-7422
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Fax | 208-736-8905
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Provider Business Mailing Address
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Address Line | 260 FALLS AVE SUITE C
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City | TWIN FALLS
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State | ID
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Zip | 83301-3370
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Country | US
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Telephone | 208-736-7422
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Fax | 208-736-8905
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363A00000X
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Taxonomy Name | Physician Assistant
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License Number | PA638
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License Number State | ID
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Taxonomy #2
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA882
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License Number State | NV
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