Provider Demographics
NPI:1841007127
Name:WILLIS, BRIAN WESLEY (AGPCNP-BC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:WESLEY
Last Name:WILLIS
Suffix:
Gender:M
Credentials:AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5920 BRASSIE PL
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-6339
Mailing Address - Country:US
Mailing Address - Phone:323-747-0470
Mailing Address - Fax:
Practice Address - Street 1:555 E TACHEVAH DR STE 2W101
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5748
Practice Address - Country:US
Practice Address - Phone:760-320-6005
Practice Address - Fax:760-323-5786
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2025-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95032580363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care