Provider Demographics
NPI:1144237298
Name:PHILLIPS, TERRY J (CRNA)
Entity Type:Individual
Prefix:
First Name:TERRY
Middle Name:J
Last Name:PHILLIPS
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 1:211 SKYLINE DRIVE
Mailing Address - Street 2:PO BOX 99
Mailing Address - City:WHITE SALMON
Mailing Address - State:WA
Mailing Address - Zip Code:98672-0099
Mailing Address - Country:US
Mailing Address - Phone:509-493-1101
Mailing Address - Fax:509-493-2838
Practice Address - Street 1:211 SKYLINE DRIVE
Practice Address - Street 2:
Practice Address - City:WHITE SALMON
Practice Address - State:WA
Practice Address - Zip Code:98672-0099
Practice Address - Country:US
Practice Address - Phone:509-493-1101
Practice Address - Fax:509-493-2838
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30003409367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAP30003409OtherARNP LICENSE NUMBER
WARN00117129OtherSTATE LICENSE NUMBER