Basic Information
| Provider Information | |||||||||
| NPI: | 1508854290 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILLIS | ||||||||
| FirstName: | NORMAN | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6489 SW BORLAND RD | ||||||||
| Address2: | |||||||||
| City: | TUALATIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970629798 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5036924843 | ||||||||
| FaxNumber: | 5036926543 | ||||||||
| Practice Location | |||||||||
| Address1: | 504 6TH ST | ||||||||
| Address2: | |||||||||
| City: | LEWISTON | ||||||||
| State: | ID | ||||||||
| PostalCode: | 835012439 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2087995600 | ||||||||
| FaxNumber: | 2087995755 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2005 | ||||||||
| LastUpdateDate: | 09/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0203X | MD09427 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Therapeutic Radiology | 2085R0001X | MD09427 | OR | N | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology | 2085R0001X | M-14114 | ID | Y | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
No ID Information.