Provider Demographics
NPI:1487815056
Name:PHILLIPS, KELLY ROBINSON (MPAS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:ROBINSON
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:MPAS, PA-C
Other - Prefix:MS
Other - First Name:KELLY
Other - Middle Name:ELIZABETH
Other - Last Name:ROBINSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPAS, PA-C
Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-852-7530
Mailing Address - Fax:336-774-0029
Practice Address - Street 1:301 E WENDOVER AVE STE 111
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1209
Practice Address - Country:US
Practice Address - Phone:336-832-7840
Practice Address - Fax:336-832-3285
Is Sole Proprietor?:No
Enumeration Date:2008-06-17
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-02044363AM0700X, 363A00000X
ORPA01364363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8101374Medicaid
ORPA01364OtherPHYSICIAN ASSISTANT LICENSE NUMBER
NC2762417Medicare PIN