Provider Demographics
NPI:1104362177
Name:STANLEY, PHILLIP TYLER (CRNA)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:TYLER
Last Name:STANLEY
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 KEATING RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-2702
Mailing Address - Country:US
Mailing Address - Phone:334-701-8240
Mailing Address - Fax:
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-793-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-13
Last Update Date:2017-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-126879367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered