Provider Demographics
NPI:1720402365
Name:TALLEY, PHILIP (FNP)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:
Last Name:TALLEY
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4519 N GARFIELD ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79705-3415
Mailing Address - Country:US
Mailing Address - Phone:432-262-4528
Mailing Address - Fax:432-201-7274
Practice Address - Street 1:4519 N GARFIELD ST
Practice Address - Street 2:SUITE 6
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79705-3415
Practice Address - Country:US
Practice Address - Phone:432-262-4528
Practice Address - Fax:432-201-7274
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2016-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02359364SF0001X
TXAP127457363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
358687YKTNMedicare UPIN