MEDICARE: SHANNON WILLS

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1306297478
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON WILLS

Provider Business Mailing Address
First Line	:	3856 YOSEMITE ST
Second Line	:
City	:	NAPA
State	:	CA
Zip	:	94558-2347
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3990 OLD TOWN AVE STE C201
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92110-2933
Country	:	US
Telephone Number	:	619-278-2400
Fax Number	:

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

Provider Enumeration Date	:	06/29/2016
Last Update Date	:	07/08/2016

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