Provider Demographics
NPI:1669187548
Name:WILLIS, RYAN (ARNP)
Entity type:Individual
Prefix:
First Name:RYAN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8097 HARBORVIEW RD
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:WA
Mailing Address - Zip Code:98230-9639
Mailing Address - Country:US
Mailing Address - Phone:360-371-5855
Mailing Address - Fax:
Practice Address - Street 1:8097 HARBORVIEW RD
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:WA
Practice Address - Zip Code:98230-9639
Practice Address - Country:US
Practice Address - Phone:360-371-5855
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-16
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP61395684363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily