Individual
JEREMY DAVID WILLES
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PAC
Contact information
Practice address
260 FALLS AVE, SUITE C, TWIN FALLS, ID 83301-3370
(208) 736-7422
(208) 736-8905
Mailing address
260 FALLS AVE, SUITE C, TWIN FALLS, ID 83301-3370
(208) 736-7422
(208) 736-8905
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
PA638
ID
363AM0700X
Medical Physician Assistant
PA882
NV
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000010161377
BLUE SHIELD
ID
01
—
000010161378
BLUE SHIELD
ID
05
—
100504125
—
NV
05
—
807683300
—
ID
05
—
807683301
—
ID
01
—
PAE68
BLUE CROSS
ID
01
—
PAE69
BLUE CROSS
ID
Enumeration date
02/07/2006
Last updated
05/08/2013
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