Provider Demographics
NPI:1689975161
Name:PHILLIPS, WILLIAM LANE JR (ARNP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:LANE
Last Name:PHILLIPS
Suffix:JR
Gender:M
Credentials:ARNP
Other - Prefix:
Other - First Name:BILL
Other - Middle Name:
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:2048 SE 16TH ST
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-6813
Mailing Address - Country:US
Mailing Address - Phone:239-940-7403
Mailing Address - Fax:
Practice Address - Street 1:3424 FOWLER ST
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-7321
Practice Address - Country:US
Practice Address - Phone:239-940-7403
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3058722363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily