Provider Demographics
NPI:1376037424
Name:MITCHELL, PHILLIP DAKOTAH
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:DAKOTAH
Last Name:MITCHELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:DAKOTAH
Other - Middle Name:
Other - Last Name:MITCHELL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:1090 ARNOLD DR
Mailing Address - Street 2:
Mailing Address - City:LR AFB
Mailing Address - State:AR
Mailing Address - Zip Code:72099-4933
Mailing Address - Country:US
Mailing Address - Phone:501-987-3080
Mailing Address - Fax:
Practice Address - Street 1:1090 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:LR AFB
Practice Address - State:AR
Practice Address - Zip Code:72099-4933
Practice Address - Country:US
Practice Address - Phone:501-987-3080
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-20
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY025056363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant