Provider Demographics
NPI:1942929666
Name:WILLIS, MADELYN
Entity type:Individual
Prefix:
First Name:MADELYN
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:412 LAIR LN
Mailing Address - Street 2:
Mailing Address - City:CANYON
Mailing Address - State:TX
Mailing Address - Zip Code:79015-4222
Mailing Address - Country:US
Mailing Address - Phone:806-418-1326
Mailing Address - Fax:
Practice Address - Street 1:2010 W KATHERINE P RAINES RD STE 300
Practice Address - Street 2:
Practice Address - City:CLEBURNE
Practice Address - State:TX
Practice Address - Zip Code:76033-7447
Practice Address - Country:US
Practice Address - Phone:432-620-1120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA18349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant