Basic Information
| Provider Information | |||||||||
| NPI: | 1992878946 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PHILLIPS | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | S | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14420 W MEEKER BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853755286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 6235375601 | ||||||||
| Practice Location | |||||||||
| Address1: | 14420 W MEEKER BLVD | ||||||||
| Address2: | SUITE 300 | ||||||||
| City: | SUN CITY WEST | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 853755286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6235375600 | ||||||||
| FaxNumber: | 6235375601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 12/06/2007 | ||||||||
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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 | 363AS0400X | 3549 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 167341 | 05 | AZ | MEDICAID |