Provider Demographics
NPI:1376258483
Name:WILLIS, ANDREW JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:JOHN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1502 S MACDILL AVE
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33629-5214
Mailing Address - Country:US
Mailing Address - Phone:813-251-0246
Mailing Address - Fax:
Practice Address - Street 1:1502 S MACDILL AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33629-5214
Practice Address - Country:US
Practice Address - Phone:813-251-0246
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-23
Last Update Date:2023-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH14322111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor