Provider Demographics
NPI:1891722096
Name:PHILLIPS, MARY KATHERINE (PA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHERINE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:K
Other - Last Name:VAUGHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1401 CENTERVILLE RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-4647
Mailing Address - Country:US
Mailing Address - Phone:850-558-1260
Mailing Address - Fax:850-558-1298
Practice Address - Street 1:2824 MAHAN DR STE 1
Practice Address - Street 2:
Practice Address - City:TALLAHASSEE
Practice Address - State:FL
Practice Address - Zip Code:32308-5429
Practice Address - Country:US
Practice Address - Phone:850-558-1260
Practice Address - Fax:850-558-1298
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9107708363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant