Individual
AUSTIN GLENN WILLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
DO
Contact information
Practice address
1100 CENTRAL AVE SE, ALBUQUERQUE, NM 87106-4930
(505) 841-1063
Mailing address
PO BOX 26666, PHS PROVIDER ENROLLMENT, ALBUQUERQUE, NM 87125-6666
(505) 923-6770
(505) 923-5354
Taxonomy
Speciality
Code
Description
License number
State
208000000X
Pediatrics Physician
Primary
A-2075-17
NM
208000000X
Pediatrics Physician
BP1-0059381
TX
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
32103778
—
NM
Enumeration date
04/18/2014
Last updated
07/21/2022
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