Healthcare Provider Details

I. General information

NPI: 1407772106
Provider Name (Legal Business Name): JOSHUA A WILLIS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/26/2026
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 MARBLE AVE NE
ALBUQUERQUE NM
87106-2058
US

IV. Provider business mailing address

2524 LA VETA DR NE
ALBUQUERQUE NM
87110-4028
US

V. Phone/Fax

Practice location:
  • Phone: 505-228-9887
  • Fax:
Mailing address:
  • Phone: 505-228-9887
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: