Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | LDO001314 | GA |
NPI | 1114959376 |
---|---|
Provider Name | Paul D Willis |
First Address | Macon, GA 31206-3027 |
Second Address | Macon, GA 31206-3027 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/07/2006 |
Last Update Date | 09/07/2007 |