Provider Demographics
NPI:1053744896
Name:ANDREA WILLEY MD A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:ANDREA WILLEY MD A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:916-922-7546
Mailing Address - Street 1:2277 FAIR OAKS BLVD
Mailing Address - Street 2:SUITE 402
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-5533
Mailing Address - Country:US
Mailing Address - Phone:916-922-7546
Mailing Address - Fax:
Practice Address - Street 1:2277 FAIR OAKS BLVD
Practice Address - Street 2:SUITE 402
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-5533
Practice Address - Country:US
Practice Address - Phone:916-922-7546
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-15
Last Update Date:2013-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA75733207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty