Provider Demographics
NPI:1477533008
Name:PHILLIPS, DESIREE (PA)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:715-838-5222
Mailing Address - Fax:
Practice Address - Street 1:700 BUFFALO ST
Practice Address - Street 2:
Practice Address - City:MONDOVI
Practice Address - State:WI
Practice Address - Zip Code:54755-1371
Practice Address - Country:US
Practice Address - Phone:715-597-3121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1277363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI42994100Medicaid
P08803Medicare UPIN