Provider Demographics
NPI:1174280366
Name:WILLIS, DAVID BRADLEY (PA-C, MPAS)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:BRADLEY
Last Name:WILLIS
Suffix:
Gender:M
Credentials:PA-C, MPAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 BLACK HAWK RD
Mailing Address - Street 2:
Mailing Address - City:VASS
Mailing Address - State:NC
Mailing Address - Zip Code:28394-9196
Mailing Address - Country:US
Mailing Address - Phone:808-462-7044
Mailing Address - Fax:
Practice Address - Street 1:1722 TAGATAY C
Practice Address - Street 2:
Practice Address - City:FORT BRAGG
Practice Address - State:NC
Practice Address - Zip Code:28307
Practice Address - Country:US
Practice Address - Phone:910-907-8282
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-22
Last Update Date:2021-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant