Basic Information
| Provider Information | |||||||||
| NPI: | 1679537294 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | MARY JO | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8007 EXCELSIOR DRIVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53717 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088295201 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Practice Location | |||||||||
| Address1: | 2880 UNIVERSITY AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 53705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082637500 | ||||||||
| FaxNumber: | 6088336932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 43266 | WI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 43829500 | 05 | WI | MEDICAID |