Provider Demographics
NPI:1790082949
Name:WILLIS, DEMETRIUS E
Entity Type:Individual
Prefix:
First Name:DEMETRIUS
Middle Name:E
Last Name:WILLIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3036 ANDRETTI LN
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052-4144
Mailing Address - Country:US
Mailing Address - Phone:702-259-2493
Mailing Address - Fax:
Practice Address - Street 1:3036 ANDRETTI LN
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89052-4144
Practice Address - Country:US
Practice Address - Phone:702-259-2493
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-24
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner