Provider Demographics
NPI:1376595215
Name:WILLIS, CAROLYN
Entity type:Individual
Prefix:
First Name:CAROLYN
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 1:208 LOGAN RD
Mailing Address - Street 2:
Mailing Address - City:GIBSONIA
Mailing Address - State:PA
Mailing Address - Zip Code:15044-6092
Mailing Address - Country:US
Mailing Address - Phone:718-344-9868
Mailing Address - Fax:
Practice Address - Street 1:118 GRAND AVE
Practice Address - Street 2:
Practice Address - City:MARS
Practice Address - State:PA
Practice Address - Zip Code:16046-3410
Practice Address - Country:US
Practice Address - Phone:412-501-9585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2025-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY226705207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI49331Medicare UPIN
NY3K6941Medicare ID - Type UnspecifiedEMPIRE MEDICARE SERVICES