Provider Demographics
NPI:1376083220
Name:STAFFORD, PHILLIP CLAYON
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:CLAYON
Last Name:STAFFORD
Suffix:
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 1:7055 E LAKE MEAD BLVD
Mailing Address - Street 2:APT 1004
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89156-1108
Mailing Address - Country:US
Mailing Address - Phone:804-729-1264
Mailing Address - Fax:
Practice Address - Street 1:7213 CHESTERTON DR
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-3121
Practice Address - Country:US
Practice Address - Phone:702-754-9136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-26
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation PractitionerGroup - Single Specialty