Provider Demographics
NPI:1447847538
Name:WILLIS HEALTH CARE PLLC
Entity type:Organization
Organization Name:WILLIS HEALTH CARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:G
Authorized Official - Last Name:WILLIS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:208-705-2575
Mailing Address - Street 1:1350 CEDAR LAKE RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83204-4946
Mailing Address - Country:US
Mailing Address - Phone:208-705-2575
Mailing Address - Fax:208-203-1348
Practice Address - Street 1:1350 CEDAR LAKE RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83204-4946
Practice Address - Country:US
Practice Address - Phone:208-705-2575
Practice Address - Fax:208-203-1348
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty