Provider Demographics
NPI:1033438320
Name:PHILLIPS, SEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1656 CHAMPLIN AVE
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:NY
Mailing Address - Zip Code:13502-4830
Mailing Address - Country:US
Mailing Address - Phone:315-624-6068
Mailing Address - Fax:315-624-6308
Practice Address - Street 1:1656 CHAMPLIN AVE
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:NY
Practice Address - Zip Code:13502-4830
Practice Address - Country:US
Practice Address - Phone:315-624-6068
Practice Address - Fax:315-624-6308
Is Sole Proprietor?:No
Enumeration Date:2010-05-26
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC059363A00000X
CT3622363AS0400X
NY016600363AS0400X
KYPA2818363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical