Provider Demographics
NPI:1326552902
Name:WILLIS, GREGORY LEE
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:LEE
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 1:325 N WIGET LN STE 130
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94598-2435
Mailing Address - Country:US
Mailing Address - Phone:925-935-5425
Mailing Address - Fax:
Practice Address - Street 1:325 N WIGET LN STE 130
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-2435
Practice Address - Country:US
Practice Address - Phone:925-935-5425
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-19
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC17472171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty