Provider Demographics
NPI:1639405749
Name:WILLS, LEAH MARIA (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:MARIA
Last Name:WILLS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 S 28TH AVE
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-7246
Mailing Address - Country:US
Mailing Address - Phone:601-264-6000
Mailing Address - Fax:601-261-3587
Practice Address - Street 1:415 S 28TH AVE
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7246
Practice Address - Country:US
Practice Address - Phone:601-268-5888
Practice Address - Fax:601-261-3587
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-23
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH002991363A00000X
MSPA00807363A00000X
NC0010-06814363A00000X
GA7385363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1639405749Medicaid