Provider Demographics
NPI:1245259027
Name:WILLNER, JAY (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:
Last Name:WILLNER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 OLD ORCHARD LN
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN TOP
Mailing Address - State:PA
Mailing Address - Zip Code:18707-1742
Mailing Address - Country:US
Mailing Address - Phone:570-881-0016
Mailing Address - Fax:
Practice Address - Street 1:100 N WILKES BARRE BLVD STE 103
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-5240
Practice Address - Country:US
Practice Address - Phone:570-846-2720
Practice Address - Fax:570-706-9629
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2023-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040729E207QA0401X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAA65003Medicare UPIN