| Physician Last Name: | Willis Avenue Medical |
| Physician First Name: | P.C. |
| Physician Middle Name: | |
| Address: | c/o John P. Donovan
33 Willis Avenue, Suite 105
Mineola, NY 11501 |
| License Number: | 098458 |
| License Type: | |
| Year of Birth: |
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| Effective Date: | 10/13/2008 |
| Action Description for DOH Webpage: | Annulment of Certificate of Incorporation |
| Misconduct Description for DOH Webpage: | The corporation admitted guilt to the charge of failing to comply with New York State Business Corporation Law Sections 1503 and 1514. |
| License Limitations or Conditions for DOH Webpage: | |
| Board Order: |
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