Provider Demographics
NPI:1881636736
Name:WILLIS, DAVID WILLIAM (NP)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:WILLIAM
Last Name:WILLIS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 GREEN RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48105-1598
Mailing Address - Country:US
Mailing Address - Phone:740-352-4127
Mailing Address - Fax:
Practice Address - Street 1:1805 27TH ST
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:OH
Practice Address - Zip Code:45662-2640
Practice Address - Country:US
Practice Address - Phone:740-356-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-12
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH279699363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P66590Medicare UPIN