Provider Demographics
NPI:1972809309
Name:JERNIGAN, PHILLIP A (PA)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:A
Last Name:JERNIGAN
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:513 BROOKWOOD BLVD
Practice Address - Street 2:SUITE 400
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-6862
Practice Address - Country:US
Practice Address - Phone:205-877-9191
Practice Address - Fax:205-877-8377
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-02
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALTA-1724363AM0700X
NC0010-08024363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Single Specialty