Provider Demographics
NPI:1811622533
Name:PHILLIPS, ALYSSA (PA)
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 MIDDLE TPKE W
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06040-3816
Mailing Address - Country:US
Mailing Address - Phone:860-533-4176
Mailing Address - Fax:
Practice Address - Street 1:515 MIDDLE TPKE W
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06040-3816
Practice Address - Country:US
Practice Address - Phone:860-553-4176
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-18
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5817363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant