Provider Demographics
NPI:1225058266
Name:PHILLIPS, LARRY C II (PAC)
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:C
Last Name:PHILLIPS
Suffix:II
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 E PINEY FOREST RD
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24540
Mailing Address - Country:US
Mailing Address - Phone:434-791-4110
Mailing Address - Fax:
Practice Address - Street 1:441 E PINEY FOREST RD
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24540
Practice Address - Country:US
Practice Address - Phone:434-791-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-20
Last Update Date:2013-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102445363A00000X
VA0110003402363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2746214Medicare ID - Type Unspecified