Provider Demographics
NPI:1649512518
Name:WILLIS, KRISTEN ALLISON (PA-C)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ALLISON
Last Name:WILLIS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 844658
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-4658
Mailing Address - Country:US
Mailing Address - Phone:254-724-8800
Mailing Address - Fax:
Practice Address - Street 1:1700 UNIVERSITY DR E
Practice Address - Street 2:
Practice Address - City:COLLEGE STATION
Practice Address - State:TX
Practice Address - Zip Code:77840-2661
Practice Address - Country:US
Practice Address - Phone:979-691-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-19
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07166363A00000X
TXPA 07166363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical