Provider Demographics
NPI:1083069025
Name:PHIPPEN, ANDREW WADE
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:WADE
Last Name:PHIPPEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2960 E CASTO LN
Mailing Address - Street 2:
Mailing Address - City:HOLLADAY
Mailing Address - State:UT
Mailing Address - Zip Code:84117-7123
Mailing Address - Country:US
Mailing Address - Phone:801-556-1866
Mailing Address - Fax:801-576-7536
Practice Address - Street 1:2960 E CASTO LN
Practice Address - Street 2:
Practice Address - City:HOLLADAY
Practice Address - State:UT
Practice Address - Zip Code:84117-7123
Practice Address - Country:US
Practice Address - Phone:801-556-1866
Practice Address - Fax:801-649-5966
Is Sole Proprietor?:No
Enumeration Date:2016-04-27
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT284016-2401208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation