Basic Information
| Provider Information | |||||||||
| NPI: | 1982792628 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHIPPS | ||||||||
| FirstName: | PATRICIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11781 LEE JACKSON MEMORIAL HWY | ||||||||
| Address2: | STE 550 | ||||||||
| City: | FAIRFAX | ||||||||
| State: | VA | ||||||||
| PostalCode: | 220333309 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5717775164 | ||||||||
| FaxNumber: | 7038902650 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 GRAND CONCOURSE | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104577606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7184668153 | ||||||||
| FaxNumber: | 7182287471 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 10/06/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 310437 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 1223G0001X | 051701 | NY | N | Dental Providers | Dentist | General Practice |
ID Information
| ID | Type | State | Issuer | Description | A40001202 | 01 | NY | MC PTAN | OTHER | 051701 | 01 | NY | LICENSE # | OTHER |