Provider Demographics
NPI:1881635019
Name:WILLIS, MILTON EVANS (PA)
Entity Type:Individual
Prefix:MR
First Name:MILTON
Middle Name:EVANS
Last Name:WILLIS
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:PO BOX 714
Mailing Address - Street 2:
Mailing Address - City:WINNIE
Mailing Address - State:TX
Mailing Address - Zip Code:77665-0714
Mailing Address - Country:US
Mailing Address - Phone:409-296-9505
Mailing Address - Fax:409-296-2506
Practice Address - Street 1:538 BROADWAY
Practice Address - Street 2:
Practice Address - City:WINNIE
Practice Address - State:TX
Practice Address - Zip Code:77665-7600
Practice Address - Country:US
Practice Address - Phone:409-296-9505
Practice Address - Fax:409-296-2506
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2009-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA00964363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8Y1053OtherBCBS
TX432066154OtherTAX ID NUMBER
TX8Y1053OtherBCBS
TX432066154OtherTAX ID NUMBER
TXR59674Medicare UPIN