Provider Demographics
NPI:1235363847
Name:WILLIS, MICHAEL L (ADULT NURSE PRACTITI)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:L
Last Name:WILLIS
Suffix:
Gender:M
Credentials:ADULT NURSE PRACTITI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 KINGS HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-2625
Mailing Address - Country:US
Mailing Address - Phone:718-677-6669
Mailing Address - Fax:
Practice Address - Street 1:3201 KINGS HIGHWAY
Practice Address - Street 2:BETH ISRAEL MEDICAL CENTER
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-2625
Practice Address - Country:US
Practice Address - Phone:718-677-6669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY302775363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health