Individual
CHARLA RAE WILLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
MD
Contact information
Practice address
2315 8TH ST, LEWISTON, ID 83501-7301
(208) 746-1383
(208) 746-6348
Mailing address
2315 8TH ST, LEWISTON, ID 83501-7301
(208) 746-1383
(208) 746-6348
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
033594
CT
207R00000X
Internal Medicine Physician
D0056472
MD
207R00000X
Internal Medicine Physician
Primary
M9369
ID
207R00000X
Internal Medicine Physician
MD00045264
WA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
0222531
LABOR & INDUSTRIES
WA
05
—
1011897
—
WA
01
—
1131387
DMERC
ID
01
—
1497846091
REGENCE BLUESHIELD
ID
05
—
1497846091
—
ID
01
—
74930
BLUE CROSS
ID
Enumeration date
09/27/2006
Last updated
03/07/2016
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