Provider Demographics
NPI:1972083137
Name:PHILLIPS, DERALD JR (PA)
Entity Type:Individual
Prefix:MR
First Name:DERALD
Middle Name:
Last Name:PHILLIPS
Suffix:JR
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 1:3605 PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79118-8197
Mailing Address - Country:US
Mailing Address - Phone:217-918-0207
Mailing Address - Fax:
Practice Address - Street 1:1901 MEDI PARK DR STE 2050
Practice Address - Street 2:
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-2109
Practice Address - Country:US
Practice Address - Phone:806-355-3352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-17
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
TXPA12454363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical