Basic Information
| Provider Information | |||||||||
| NPI: | 1881644425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHILIPS | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | A. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILT | ||||||||
| OtherFirstName: | PATRICIA | ||||||||
| OtherMiddleName: | A. | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 40767 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322030767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9043763707 | ||||||||
| FaxNumber: | 9043915807 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR STE 180 | ||||||||
| Address2: | CREDENTIALING DEPARTMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078350 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042024600 | ||||||||
| FaxNumber: | 9042024638 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/12/2006 | ||||||||
| LastUpdateDate: | 02/03/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | RN301574 | OH | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | ARNP9264953 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | P01006233 | 01 | FL | RR MEDICARE | OTHER |