Provider Demographics
NPI:1205142023
Name:WILLIS, JOSH MAURICE
Entity type:Individual
Prefix:MR
First Name:JOSH
Middle Name:MAURICE
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 1:3230 HIGHWAY 42
Mailing Address - Street 2:SUITE F
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-4667
Mailing Address - Country:US
Mailing Address - Phone:770-389-9110
Mailing Address - Fax:678-302-7675
Practice Address - Street 1:3230 HIGHWAY 42
Practice Address - Street 2:SUITE F
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-4667
Practice Address - Country:US
Practice Address - Phone:770-389-9110
Practice Address - Fax:678-302-7675
Is Sole Proprietor?:No
Enumeration Date:2010-08-31
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA075-09146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic