Provider Demographics
NPI:1760441356
Name:IRWIN, PHILIP BLACKBURN (P A)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:BLACKBURN
Last Name:IRWIN
Suffix:
Gender:M
Credentials:P A
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:353 NW EESTAULKEE AVE
Mailing Address - Street 2:P. O. BOX 678
Mailing Address - City:MICANOPY
Mailing Address - State:FL
Mailing Address - Zip Code:32667-4068
Mailing Address - Country:US
Mailing Address - Phone:352-466-3862
Mailing Address - Fax:352-379-7492
Practice Address - Street 1:1601 SW ARCHER RD
Practice Address - Street 2:#112
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1135
Practice Address - Country:US
Practice Address - Phone:352-376-1611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3387363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical