1679649396 NPI number — STUART KENDALL WILLIS III MD

Table of content: STUART KENDALL WILLIS III MD (NPI 1679649396)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679649396 NPI number — STUART KENDALL WILLIS III MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILLIS
Provider First Name:
STUART
Provider Middle Name:
KENDALL
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILLIS
Provider Other First Name:
HENRY
Provider Other Middle Name:
STUART KENDALL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
III
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1679649396
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
HCR 85 BOX 8133
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BONNERS FERRY
Provider Business Mailing Address State Name:
ID
Provider Business Mailing Address Postal Code:
83805-7532
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
208-267-6365
Provider Business Mailing Address Fax Number:
208-267-2202

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6640 KANIKSU ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BONNERS FERRY
Provider Business Practice Location Address State Name:
ID
Provider Business Practice Location Address Postal Code:
83805-7532
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
208-267-4850
Provider Business Practice Location Address Fax Number:
208-267-2202
Provider Enumeration Date:
11/27/2006

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: 207P00000X , with the licence number:  M9300 , registered in the state of ID ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: M9300 . This is a "ID B OF M" identifier , issued by the state of ( ID ) . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com