Provider Demographics
NPI:1104538834
Name:WILLIS, THOMAS JAMES (ACNPC-AG)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:JAMES
Last Name:WILLIS
Suffix:
Gender:M
Credentials:ACNPC-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7606 SW 65TH PLACE RD
Mailing Address - Street 2:
Mailing Address - City:OCALA
Mailing Address - State:FL
Mailing Address - Zip Code:34474-1647
Mailing Address - Country:US
Mailing Address - Phone:352-454-5983
Mailing Address - Fax:
Practice Address - Street 1:2111 SW 20TH PL
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34471-7734
Practice Address - Country:US
Practice Address - Phone:352-547-3399
Practice Address - Fax:352-622-0102
Is Sole Proprietor?:No
Enumeration Date:2022-12-13
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11023470363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care