MEDICARE: TIMOTHY JASON WILLETT H.A.S.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	237700000X	Hearing Instrument Specialist	AS 4908	FL

General Provider Information

NPI Number	:	1114261021
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TIMOTHY JASON WILLETT H.A.S.

Provider Business Mailing Address
First Line	:	1615 RIDGEWOOD AVE # B
Second Line	:
City	:	HOLLY HILL
State	:	FL
Zip	:	32117-1798
Country	:	US
Telephone Number	:	386-673-3366
Fax Number	:	386-615-0990

Provider Business Practice Location Address
First Line	:	1615 RIDGEWOOD AVE # B
Second Line	:
City	:	HOLLY HILL
State	:	FL
Zip	:	32117-1798
Country	:	US
Telephone Number	:	386-673-3366
Fax Number	:	386-615-0990

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/15/2012
Last Update Date	:	11/02/2015

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