Basic Information
| Provider Information | |||||||||
| NPI: | 1740768076 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLSON | ||||||||
| FirstName: | DEVIN | ||||||||
| MiddleName: | |||||||||
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| Credential: | BT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1350 HILLRISE CIR | ||||||||
| Address2: | |||||||||
| City: | LAS CRUCES | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880114759 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5755229500 | ||||||||
| FaxNumber: | 5755231108 | ||||||||
| Practice Location | |||||||||
| Address1: | 6013 S REDWOOD RD | ||||||||
| Address2: | |||||||||
| City: | TAYLORSVILLE | ||||||||
| State: | UT | ||||||||
| PostalCode: | 841235220 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8012555131 | ||||||||
| FaxNumber: | 8016580604 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/30/2018 | ||||||||
| LastUpdateDate: | 09/01/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.