Provider Demographics
NPI:1881873776
Name:WILLIS, KARIN (MD)
Entity type:Individual
Prefix:DR
First Name:KARIN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 E ROSSER AVE
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4461
Mailing Address - Country:US
Mailing Address - Phone:701-751-9500
Mailing Address - Fax:701-751-9508
Practice Address - Street 1:701 E ROSSER AVE
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4461
Practice Address - Country:US
Practice Address - Phone:701-751-9500
Practice Address - Fax:701-751-9508
Is Sole Proprietor?:No
Enumeration Date:2007-10-29
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND10638207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1455094Medicaid
NDN714878Medicare PIN
ND1455094Medicaid