Provider Demographics
NPI:1376773507
Name:SWYGART, WILLIS LEE (RCS)
Entity Type:Individual
Prefix:MR
First Name:WILLIS
Middle Name:LEE
Last Name:SWYGART
Suffix:
Gender:M
Credentials:RCS
Other - Prefix:MR
Other - First Name:WILLIE
Other - Middle Name:LEE
Other - Last Name:SWYGART
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RCS
Mailing Address - Street 1:859 GABRIEL RD
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55119-5602
Mailing Address - Country:US
Mailing Address - Phone:952-240-3081
Mailing Address - Fax:
Practice Address - Street 1:859 GABRIEL RD
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55119-5602
Practice Address - Country:US
Practice Address - Phone:952-240-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-22
Last Update Date:2009-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN63270246XS1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246XS1301XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist CardiovascularSonography