Provider Demographics
NPI:1154838886
Name:WILLIS, MARK (FNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4946
Mailing Address - Country:US
Mailing Address - Phone:208-705-2575
Mailing Address - Fax:208-203-1348
Practice Address - Street 1:1350 CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4946
Practice Address - Country:US
Practice Address - Phone:208-705-2575
Practice Address - Fax:208-203-1348
Is Sole Proprietor?:No
Enumeration Date:2018-01-03
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID57490363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily