1063534253 NPI number — KRISTIN L. WILLIS PA-C

Table of content: KRISTIN L. WILLIS PA-C (NPI 1063534253)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1063534253 NPI number — KRISTIN L. WILLIS PA-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
KRISTIN
Provider Middle Name:
L.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA-C
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WOOD
Provider Other First Name:
KRISTIN
Provider Other Middle Name:
L.
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA-C
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1063534253
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/01/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 W RAMPART ST
Provider Second Line Business Mailing Address:
STE 200
Provider Business Mailing Address City Name:
SHELBYVILLE
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46176-8846
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
317-421-2012
Provider Business Mailing Address Fax Number:
317-398-1851

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2451 INTELLIPLEX DR
Provider Second Line Business Practice Location Address:
STE 260
Provider Business Practice Location Address City Name:
SHELBYVILLE
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46176-8580
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
317-398-0121
Provider Business Practice Location Address Fax Number:
317-398-0538
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  085-002954 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363A00000X , with the licence number: 10003196A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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