Basic Information
| Provider Information | |||||||||
| NPI: | 1205454402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLMORE | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | K | ||||||||
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| OtherLastName: | WELSH | ||||||||
| OtherFirstName: | ALEXIS | ||||||||
| OtherMiddleName: | K | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1015 CAMBRIDGE DR | ||||||||
| Address2: | |||||||||
| City: | KALAMAZOO | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490014414 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2692904331 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3950 HOLLYWOOD RD STE 280 | ||||||||
| Address2: | |||||||||
| City: | SAINT JOSEPH | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490859151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699825864 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2020 | ||||||||
| LastUpdateDate: | 10/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 5601010094 | MI | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363A00000X | 5601010094 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.