Healthcare Provider Details

I. General information

NPI: 1477266385
Provider Name (Legal Business Name): PETER WILLIS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2023
Last Update Date: 01/05/2023
Certification Date: 01/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2474 SW PERKINS AVE
PENDLETON OR
97801-4302
US

IV. Provider business mailing address

PO BOX 1517
PENDLETON OR
97801-0410
US

V. Phone/Fax

Practice location:
  • Phone: 541-966-6638
  • Fax: 541-276-6327
Mailing address:
  • Phone: 877-708-1119
  • Fax: 541-278-8349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number10002005
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: