Provider Demographics
NPI:1851451140
Name:FORD, PHILIP DOUGLAS (PA-C)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:DOUGLAS
Last Name:FORD
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 HOWE AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825-4604
Mailing Address - Country:US
Mailing Address - Phone:916-972-1100
Mailing Address - Fax:
Practice Address - Street 1:5255 ELKHORN BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95842-2506
Practice Address - Country:US
Practice Address - Phone:916-334-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-09
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13263363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA13263OtherPA LICSENSE
CAMF0498433OtherDEA LICSENSE