Provider Demographics
NPI:1285334201
Name:WILLIS, TYRA
Entity type:Individual
Prefix:
First Name:TYRA
Middle Name:
Last Name:WILLIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4614 WESTGARDEN PL
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77449-2380
Mailing Address - Country:US
Mailing Address - Phone:409-242-9120
Mailing Address - Fax:
Practice Address - Street 1:9740 BARKER CYPRESS RD STE 108
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77433-1974
Practice Address - Country:US
Practice Address - Phone:281-944-8013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1131656363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily