Provider Demographics
NPI:1083280119
Name:WILLIS, BENJAMIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3008 16TH AVE W APT 625
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98119-4612
Mailing Address - Country:US
Mailing Address - Phone:253-666-2490
Mailing Address - Fax:
Practice Address - Street 1:3008 16TH AVE W APT 625
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98119-4612
Practice Address - Country:US
Practice Address - Phone:253-666-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-30
Last Update Date:2021-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date: