Provider Demographics
NPI:1629292883
Name:WILLIS, NICHOLAS (MD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 W 40TH AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:PINE BLUFF
Mailing Address - State:AR
Mailing Address - Zip Code:71603-6319
Mailing Address - Country:US
Mailing Address - Phone:870-541-4285
Mailing Address - Fax:870-541-4297
Practice Address - Street 1:1601 W 40TH AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:PINE BLUFF
Practice Address - State:AR
Practice Address - Zip Code:71603-6319
Practice Address - Country:US
Practice Address - Phone:870-541-4285
Practice Address - Fax:870-541-4297
Is Sole Proprietor?:No
Enumeration Date:2007-04-12
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE5292207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR168857001Medicaid
AR168857001Medicaid