Provider Demographics
NPI:1851950190
Name:PHILLIPS, GREGORY (NP)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14309 248TH ST
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2139
Mailing Address - Country:US
Mailing Address - Phone:646-210-7568
Mailing Address - Fax:
Practice Address - Street 1:14309 248TH ST
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2139
Practice Address - Country:US
Practice Address - Phone:646-210-7568
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-11
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY615347163WE0003X
NY345053363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency