Provider Demographics
NPI:1407066764
Name:WILLEY, METTA ELIZABETH KOHN (MD)
Entity type:Individual
Prefix:DR
First Name:METTA
Middle Name:ELIZABETH KOHN
Last Name:WILLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:24988 SE STARK ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRESHAM
Mailing Address - State:OR
Mailing Address - Zip Code:97030-8322
Mailing Address - Country:US
Mailing Address - Phone:503-667-8878
Mailing Address - Fax:
Practice Address - Street 1:24988 SE STARK ST
Practice Address - Street 2:SUITE 200
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8322
Practice Address - Country:US
Practice Address - Phone:503-667-8878
Practice Address - Fax:503-667-0310
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLL16142208000000X
ORMD27561208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics