Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207N00000X | Dermatologist | M7012 | ID |
N | 207ND0101X | MOHS-Micrographic Surgeon | M7012 | ID |
Y | 207ND0101X | MOHS-Micrographic Surgeon | MD054641L | PA |
N | 207NS0135X | Procedural Dermatology | M7012 | ID |
NPI | 1407800501 |
---|---|
Provider Name | James R Willis |
First Address | Danville, PA 17822-4903 |
Second Address | Danville, PA 17822-8029 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/05/2006 |
Last Update Date | 10/08/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
000278700 | (05) | ID |
G30838 | (02) | ID |