Provider Demographics
NPI:1104363258
Name:WILLIS, BRENT (CRNA)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 LA GRANGE DR.
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75501
Mailing Address - Country:US
Mailing Address - Phone:936-645-5428
Mailing Address - Fax:
Practice Address - Street 1:203 LA GRANGE DR.
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75501
Practice Address - Country:US
Practice Address - Phone:936-645-5428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP133014367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered