Provider Demographics
NPI:1053430488
Name:WILLETTE, REGINA M (RPA C)
Entity type:Individual
Prefix:MS
First Name:REGINA
Middle Name:M
Last Name:WILLETTE
Suffix:
Gender:F
Credentials:RPA C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:80 STATE HIGHWAY 310
Mailing Address - Street 2:SUITE 1
Mailing Address - City:CANTON
Mailing Address - State:NY
Mailing Address - Zip Code:13617-1493
Mailing Address - Country:US
Mailing Address - Phone:315-386-2189
Mailing Address - Fax:315-386-2435
Practice Address - Street 1:80 STATE HIGHWAY 310
Practice Address - Street 2:SUITE 1
Practice Address - City:CANTON
Practice Address - State:NY
Practice Address - Zip Code:13617-1493
Practice Address - Country:US
Practice Address - Phone:315-386-2189
Practice Address - Fax:315-386-2435
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2008-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY3588363A00000X
NY001128176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYCC6535Medicare PIN