Provider Demographics
NPI:1770875502
Name:ENNIS, WILLIS ASHTON (MD)
Entity type:Individual
Prefix:
First Name:WILLIS
Middle Name:ASHTON
Last Name:ENNIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:169 ASHLEY AVE
Mailing Address - Street 2:ROOM 202 MAIN HOSPITAL
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29425-8905
Mailing Address - Country:US
Mailing Address - Phone:843-792-2300
Mailing Address - Fax:
Practice Address - Street 1:169 ASHLEY AVE
Practice Address - Street 2:ROOM 202 MAIN HOSPITAL
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29425-8905
Practice Address - Country:US
Practice Address - Phone:843-792-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD440173207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology