Provider Demographics
NPI:1154501757
Name:PHILLIPS, TERRA R (PA-C)
Entity Type:Individual
Prefix:MS
First Name:TERRA
Middle Name:R
Last Name:PHILLIPS
Suffix:
Gender:F
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 1:6400 FANNIN ST STE 2070
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1541
Mailing Address - Country:US
Mailing Address - Phone:713-704-6731
Mailing Address - Fax:713-704-6889
Practice Address - Street 1:1120 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 150
Practice Address - City:SHENANDOAH
Practice Address - State:TX
Practice Address - Zip Code:77380-3242
Practice Address - Country:US
Practice Address - Phone:713-897-5900
Practice Address - Fax:713-897-2202
Is Sole Proprietor?:No
Enumeration Date:2007-11-12
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA05101363AM0700X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX153449704Medicaid
TX153449706Medicaid
TX00X185Medicare UPIN
TX153449704Medicaid
TX00659NMedicare UPIN
TX153449704Medicaid