=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912254400
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JAMES AUSTIN WILLIS DPT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/14/2012
-----------------------------------------------------
Last Update Date | 09/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3800 JOE RAMSEY BLVD E STE B
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75401-7778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-355-2902
-----------------------------------------------------
Fax | 903-355-2909
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3800 JOE RAMSEY BLVD E STE B
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75401-7778
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 903-355-2902
-----------------------------------------------------
Fax | 903-355-2909
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 1220302
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------