Provider Demographics
NPI:1265587166
Name:WILLIS, TERESA (PA)
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8608 IRON GATE CT
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76179-3024
Mailing Address - Country:US
Mailing Address - Phone:817-927-2332
Mailing Address - Fax:817-927-0361
Practice Address - Street 1:8608 IRON GATE CT
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76179-3024
Practice Address - Country:US
Practice Address - Phone:817-927-2332
Practice Address - Fax:817-927-0361
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA02067363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant