Provider Demographics
NPI:1588674246
Name:PHILLIPS, MICHAEL WAYNE (CRNA)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:WAYNE
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7390 GIRAFFE RD
Mailing Address - Street 2:
Mailing Address - City:GILMER
Mailing Address - State:TX
Mailing Address - Zip Code:75644
Mailing Address - Country:US
Mailing Address - Phone:903-725-5267
Mailing Address - Fax:903-725-6436
Practice Address - Street 1:719 W COKE RD
Practice Address - Street 2:PRESBYTERIAN HOSPITAL WINNSBORO
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494
Practice Address - Country:US
Practice Address - Phone:903-342-5227
Practice Address - Fax:903-342-4121
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRN545795367500000X
TXCRNA41986367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX84759UOtherBLUE CROSS BLUE SHIELD
TX003290602Medicaid
TX84759UOtherBLUE CROSS BLUE SHIELD