Provider Demographics
NPI:1205663069
Name:WILLIS, TYLER AUSTIN (RN)
Entity type:Individual
Prefix:
First Name:TYLER
Middle Name:AUSTIN
Last Name:WILLIS
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11453 69TH PL S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-3002
Mailing Address - Country:US
Mailing Address - Phone:425-466-3781
Mailing Address - Fax:
Practice Address - Street 1:3000 LANDERHOLM CIR SE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-6484
Practice Address - Country:US
Practice Address - Phone:425-466-3781
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN61080655364SA2100X, 390200000X, 163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program