Basic Information
| Provider Information | |||||||||
| NPI: | 1114483518 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 220 PAUL AVE | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891062740 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7252030007 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 408 S JONES BLVD | ||||||||
| Address2: | |||||||||
| City: | LAS VEGAS | ||||||||
| State: | NV | ||||||||
| PostalCode: | 891072658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7025028021 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2019 | ||||||||
| LastUpdateDate: | 02/11/2019 | ||||||||
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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 | 106S00000X | Y |
ID Information
| ID | Type | State | Issuer | Description | 00001749386 | 05 | NV | MEDICAID |