Basic Information
| Provider Information | |||||||||
| NPI: | 1356810865 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLE | ||||||||
| FirstName: | COURTNEY | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 820 OAKWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | OAKWOOD | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454192937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9375461520 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 23RD ST | ||||||||
| Address2: | |||||||||
| City: | CUYAHOGA FALLS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442231404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3305630618 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2018 | ||||||||
| LastUpdateDate: | 11/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 50.005801RX | OH | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.