Provider Demographics
NPI:1740408475
Name:WILLIS, GREGORY (CRNA)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1015 STATE ROUTE 121
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:IL
Mailing Address - Zip Code:62656-5355
Mailing Address - Country:US
Mailing Address - Phone:217-792-3864
Mailing Address - Fax:
Practice Address - Street 1:200 STAHLHUT DR
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:IL
Practice Address - Zip Code:62656-5066
Practice Address - Country:US
Practice Address - Phone:217-732-2161
Practice Address - Fax:217-735-3526
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-20
Last Update Date:2011-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001819367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37699OtherRECERTIFICATION OF CRNA