Basic Information
| Provider Information | |||||||||
| NPI: | 1215902473 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PAUL | ||||||||
| FirstName: | WILLIS | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 320 E NORTH AVE | ||||||||
| Address2: | |||||||||
| City: | PITTSBURGH | ||||||||
| State: | PA | ||||||||
| PostalCode: | 152124756 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4123593155 | ||||||||
| FaxNumber: | 4123593483 | ||||||||
| Practice Location | |||||||||
| Address1: | 4121 MONROEVILLE BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151462607 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8772576272 | ||||||||
| FaxNumber: | 4123433769 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2006 | ||||||||
| LastUpdateDate: | 11/19/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | RN252958L | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 001942022 | 05 | PA | MEDICAID |