Provider Demographics
NPI:1487755849
Name:WILLIS, JAMES SCOTT (CRNA)
Entity type:Individual
Prefix:
First Name:JAMES
Middle Name:SCOTT
Last Name:WILLIS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8225
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705-0225
Mailing Address - Country:US
Mailing Address - Phone:304-399-0137
Mailing Address - Fax:304-399-0138
Practice Address - Street 1:2900 1ST AVE
Practice Address - Street 2:#6019
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25702-1241
Practice Address - Country:US
Practice Address - Phone:304-399-0137
Practice Address - Fax:304-399-0138
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2013-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV40738367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV001720989OtherMTN STATE BCBS
WV0068445000Medicaid
OH0343079Medicaid
P00219014OtherRAILROAD MEDICARE
WV001720989OtherMTN STATE BCBS