Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207P00000X | Emergency Physician | 070013 | GA |
Y | 207P00000X | Emergency Physician | OT012855 | PA |
N | 207PP0204X | Pediatric Emergency Physician | 070013 | GA |
NPI | 1780819771 |
---|---|
Provider Name | Jon Willardson |
First Address | Augusta, GA 30912-0004 |
Second Address | Augusta, GA 30912-0004 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/05/2009 |
Last Update Date | 25/06/2013 |