Provider Demographics
NPI:1891120127
Name:MAXWELL, PHILLIP (PA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:MAXWELL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 W COLONIAL DR APT 3108
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-7310
Mailing Address - Country:US
Mailing Address - Phone:631-697-0634
Mailing Address - Fax:
Practice Address - Street 1:1707 N MILLS AVE
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-1851
Practice Address - Country:US
Practice Address - Phone:407-647-3960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2022-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical