Provider Demographics
NPI:1588033369
Name:REZA, PHILLIP ANTHONY (PRACTICAL NURSE)
Entity Type:Individual
Prefix:MR
First Name:PHILLIP
Middle Name:ANTHONY
Last Name:REZA
Suffix:
Gender:M
Credentials:PRACTICAL NURSE
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1515 NE LAWRIE TATUM RD
Mailing Address - Street 2:
Mailing Address - City:LAWTON
Mailing Address - State:OK
Mailing Address - Zip Code:73507-3002
Mailing Address - Country:US
Mailing Address - Phone:580-354-5270
Mailing Address - Fax:580-354-5289
Practice Address - Street 1:1515 NE LAWRIE TATUM RD
Practice Address - Street 2:
Practice Address - City:LAWTON
Practice Address - State:OK
Practice Address - Zip Code:73507-3002
Practice Address - Country:US
Practice Address - Phone:580-354-5270
Practice Address - Fax:580-354-5289
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-22
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OKL0021375164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse