Provider Demographics
NPI:1891419883
Name:PHILLIPS, ROBERT RAYMOND (FNP- BC)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:RAYMOND
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:FNP- BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:163 CHICO HOLW
Mailing Address - Street 2:
Mailing Address - City:ALKOL
Mailing Address - State:WV
Mailing Address - Zip Code:25501-1104
Mailing Address - Country:US
Mailing Address - Phone:304-524-2310
Mailing Address - Fax:
Practice Address - Street 1:700 TECHNOLOGY DR
Practice Address - Street 2:
Practice Address - City:SOUTH CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25309-8571
Practice Address - Country:US
Practice Address - Phone:304-429-6741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV107660363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care