Healthcare Provider Details

I. General information

NPI: 1356140867
Provider Name (Legal Business Name): NATHAN WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2025
Last Update Date: 07/07/2025
Certification Date: 07/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

524 MOYE BLVD
GREENVILLE NC
27834-2848
US

IV. Provider business mailing address

275 BETHESDA DR
GREENVILLE NC
27834-7217
US

V. Phone/Fax

Practice location:
  • Phone: 252-816-2273
  • Fax:
Mailing address:
  • Phone: 423-956-6561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: