Provider Demographics
NPI:1841723681
Name:WILLIS, JUSTIN LAWRENCE (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:LAWRENCE
Last Name:WILLIS
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:PO BOX 5371
Mailing Address - Street 2:818-RC
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98145
Mailing Address - Country:US
Mailing Address - Phone:206-987-2000
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-08
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD61440877208000000X
AK160483208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics