Provider Demographics
NPI:1003841560
Name:PHILLIPS, TONY (PA)
Entity Type:Individual
Prefix:
First Name:TONY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:312 N PACIFIC ST
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:TX
Mailing Address - Zip Code:75773-1712
Mailing Address - Country:US
Mailing Address - Phone:903-569-0020
Mailing Address - Fax:
Practice Address - Street 1:312 N PACIFIC ST
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:TX
Practice Address - Zip Code:75773-1712
Practice Address - Country:US
Practice Address - Phone:903-569-0020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1129363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
P33365Medicare UPIN