Provider Demographics
NPI:1043315187
Name:WILLIS, SUSAN (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
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 1:3123 FAIRVIEW AVE E
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98102-3051
Mailing Address - Country:US
Mailing Address - Phone:206-324-4500
Mailing Address - Fax:206-328-1257
Practice Address - Street 1:3123 FAIRVIEW AVE E
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98102-3051
Practice Address - Country:US
Practice Address - Phone:206-324-4500
Practice Address - Fax:206-328-1257
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000280032084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1066174Medicaid
WAE98471Medicare UPIN