Provider Demographics
NPI:1790037539
Name:WILLS, GARY (RN)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WILLS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 ROSEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:CENTRAL ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11722-4705
Mailing Address - Country:US
Mailing Address - Phone:631-264-5139
Mailing Address - Fax:
Practice Address - Street 1:3 ROSEWOOD ST
Practice Address - Street 2:
Practice Address - City:CENTRAL ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11722-4705
Practice Address - Country:US
Practice Address - Phone:631-264-5139
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY518647163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse