Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 1223E0200X | Endodontist | 00203801 | CO |
N | 1223E0200X | Endodontist | 1517 | WY |
NPI | 1013293760 |
---|---|
Provider Name | Dr. Jon R Willison |
First Address | Fort Collins, CO 80528-6100 |
Second Address | Fort Collins, CO 80528-6100 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/10/2011 |
Last Update Date | 11/12/2019 |