Provider Demographics
NPI:1891783346
Name:PHILLIPS, MICHAEL A (CRNA)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:A
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:ULYSSES
Mailing Address - State:KS
Mailing Address - Zip Code:67880-2133
Mailing Address - Country:US
Mailing Address - Phone:620-356-1266
Mailing Address - Fax:
Practice Address - Street 1:415 N MAIN ST
Practice Address - Street 2:
Practice Address - City:ULYSSES
Practice Address - State:KS
Practice Address - Zip Code:67880-2133
Practice Address - Country:US
Practice Address - Phone:620-356-1266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-10
Last Update Date:2022-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC040596367500000X
KS557410367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2609520Medicare ID - Type Unspecified