Individual
FREDERICK WILLIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
3584 JEROME AVE, BRONX, NY 10467-1006
(718) 653-1537
Mailing address
79 GLENRIDGE RD, GLENVILLE, NY 12302-4523
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
4259
NY
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
01420795
—
NY
Enumeration date
09/19/2022
Last updated
09/19/2022
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