Basic Information
| Provider Information | |||||||||
| NPI: | 1558989566 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | STEVEN | ||||||||
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| Credential: | FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 650859 | ||||||||
| Address2: | DEPT 710 | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75265 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097476240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2785 GULF FWY S | ||||||||
| Address2: | |||||||||
| City: | LEAGUE CITY | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775734979 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8325050139 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2020 | ||||||||
| LastUpdateDate: | 09/07/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP144849 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | AP144849 | 01 | TX | TEXAS STATE BOARD OF EXAMINERS | OTHER | 870307 | 01 | TX | TEXAS BOARD OF NURSING | OTHER |