Healthcare Provider Details

I. General information

NPI: 1659208718
Provider Name (Legal Business Name): BRUCE JAMES WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2026
Last Update Date: 05/05/2026
Certification Date: 04/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2259 E SAN TAN DR
GILBERT AZ
85296-3912
US

IV. Provider business mailing address

2259 E SAN TAN DR
GILBERT AZ
85296-3912
US

V. Phone/Fax

Practice location:
  • Phone: 480-241-7175
  • Fax:
Mailing address:
  • Phone: 480-241-7175
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number338409
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: