Basic Information
| Provider Information | |||||||||
| NPI: | 1013531177 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | EAN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 112727 | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326112727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737002 | ||||||||
| FaxNumber: | 3522737388 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 SW ARCHER RD | ||||||||
| Address2: | |||||||||
| City: | GAINESVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 326102245 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522737002 | ||||||||
| FaxNumber: | 3522737388 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2020 | ||||||||
| LastUpdateDate: | 01/19/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/19/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 363A00000X | PA9113414 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.