Provider Demographics
NPI:1356140867
Name:WILLIS, NATHAN
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4502 LAUREL RIDGE DR UNIT B
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-2552
Mailing Address - Country:US
Mailing Address - Phone:423-956-6561
Mailing Address - Fax:
Practice Address - Street 1:524 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-2848
Practice Address - Country:US
Practice Address - Phone:252-816-2273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant