Provider Demographics
NPI:1942857545
Name:WILLIS, MATTHEW JOSEPH (APN)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:WILLIS
Suffix:
Gender:M
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST STE 200
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2035
Mailing Address - Country:US
Mailing Address - Phone:309-672-5682
Mailing Address - Fax:309-672-3147
Practice Address - Street 1:1001 MAIN ST STE 200
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2035
Practice Address - Country:US
Practice Address - Phone:309-672-5682
Practice Address - Fax:309-672-3147
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2019-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209019778363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner