Provider Demographics
NPI:1689606709
Name:SALLIS, WILLIE EARL (PA)
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:EARL
Last Name:SALLIS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 ANDREWS AVE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC BLDING
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-0701
Mailing Address - Country:US
Mailing Address - Phone:334-255-7349
Mailing Address - Fax:
Practice Address - Street 1:301 ANDREWS AVE
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC BLDING
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-0701
Practice Address - Country:US
Practice Address - Phone:334-255-7349
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant