Basic Information
| Provider Information | |||||||||
| NPI: | 1184614703 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8 WHITAKER LN | ||||||||
| Address2: | |||||||||
| City: | GROTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014501986 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 WRIGHT ST | ||||||||
| Address2: | |||||||||
| City: | PALMER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 010691138 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4132837651 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 09/02/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 151956 | MA | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 110058602A | 05 | MA | MEDICAID |