Provider Demographics
NPI:1982186268
Name:WILLIS, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
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 1:133 PENNWICK DR
Mailing Address - Street 2:
Mailing Address - City:LITITZ
Mailing Address - State:PA
Mailing Address - Zip Code:17543-7628
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:133 N RIVER ST
Practice Address - Street 2:
Practice Address - City:CITY OF WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-2404
Practice Address - Country:US
Practice Address - Phone:570-208-5900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-03
Last Update Date:2018-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic TrainerGroup - Single Specialty