Provider Demographics
NPI:1205358843
Name:HERRING, PHILLIP MARTIN II
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:MARTIN
Last Name:HERRING
Suffix:II
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 1:11258 WINDSOR PLACE CIR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33626-2688
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11258 WINDSOR PLACE CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33626-2688
Practice Address - Country:US
Practice Address - Phone:773-669-4821
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-15
Last Update Date:2017-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043111308164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL1578644431OtherBAY PINES VA HEALTH CARE SYSTEMS