Basic Information
| Provider Information | |||||||||
| NPI: | 1326059692 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLEY | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | O'BRYAN | ||||||||
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| Credential: | P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3737 SOUTHERN BLVD STE 2100 | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291285 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374335309 | ||||||||
| FaxNumber: | 9372980287 | ||||||||
| Practice Location | |||||||||
| Address1: | 3737 SOUTHERN BLVD | ||||||||
| Address2: | SUITE 2100 | ||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454291225 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374335309 | ||||||||
| FaxNumber: | 9372980287 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/11/2006 | ||||||||
| LastUpdateDate: | 11/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50002155 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AS0400X | 2155 | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 349758 | 01 | OH | ANTHEM | OTHER | P00182934 | 01 | OH | MEDICARE RAILROAD | OTHER | P00182934 | 01 | OH | MEDICARE ID | OTHER |