Provider Demographics
NPI:1679853477
Name:PHILLIPS, CARL DOUGLAS JR (FNP-C)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:DOUGLAS
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 IDLEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3455
Mailing Address - Country:US
Mailing Address - Phone:337-400-4683
Mailing Address - Fax:
Practice Address - Street 1:109 YORKTOWN DR STE A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71303-3673
Practice Address - Country:US
Practice Address - Phone:318-542-4288
Practice Address - Fax:318-704-6201
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-24
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06562363LP0808X
LARN115788-AP06562363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2160648Medicaid