Healthcare Provider Details

I. General information

NPI: 1407199706
Provider Name (Legal Business Name): WILLIAM ENNIS JR. P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2013
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

914A EASTERN SHORE DR
SALISBURY MD
21804-6410
US

IV. Provider business mailing address

914A EASTERN SHORE DR
SALISBURY MD
21804-6410
US

V. Phone/Fax

Practice location:
  • Phone: 410-546-1331
  • Fax: 410-543-8107
Mailing address:
  • Phone: 410-546-1331
  • Fax: 410-543-8107

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberC05019
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: