Basic Information
| Provider Information | |||||||||
| NPI: | 1104362177 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | PHILLIP | ||||||||
| MiddleName: | TYLER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | C.R.N.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1600 KEATING RD | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363032702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347018240 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1118 ROSS CLARK CIR | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2017 | ||||||||
| LastUpdateDate: | 01/13/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 1-126879 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.