Healthcare Provider Details

I. General information

NPI: 1972327120
Provider Name (Legal Business Name): ANTHONY K WILLIS PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 11/14/2024
Certification Date: 11/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 CATHERINE SIMMONS AVE
CHARLOTTE NC
28216-4677
US

IV. Provider business mailing address

326 HONEYWOOD AVE
CHARLOTTE NC
28216-4041
US

V. Phone/Fax

Practice location:
  • Phone: 704-492-1533
  • Fax:
Mailing address:
  • Phone: 910-391-0608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code405300000X
TaxonomyPrevention Professional
License Number2024-12086-01
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: