MEDICARE: SUSAN M. WILLIS CRNA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	367500000X	Certified Registered Nurse Anesthetist	542468	TX
2	367500000X	Certified Registered Nurse Anesthetist	AP101864	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	89479C	OTHER	TX	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1619975448
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUSAN M. WILLIS CRNA

Provider Business Mailing Address
First Line	:	PO BOX 840853 STE 600
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75284-4823
Country	:	US
Telephone Number	:	972-233-1999
Fax Number	:	972-233-3666

Provider Business Practice Location Address
First Line	:	7205 LAKE MEAD BLVD
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-4137
Country	:	US
Telephone Number	:	817-563-9211
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	12/09/2021

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