Provider Demographics
NPI:1134208663
Name:PHILLIPS, JEFFREY DON (PA)
Entity type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:DON
Last Name:PHILLIPS
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 1:429 W ELM ST
Mailing Address - Street 2:
Mailing Address - City:HOBART
Mailing Address - State:OK
Mailing Address - Zip Code:73651-1615
Mailing Address - Country:US
Mailing Address - Phone:580-726-3324
Mailing Address - Fax:
Practice Address - Street 1:429 W ELM ST
Practice Address - Street 2:
Practice Address - City:HOBART
Practice Address - State:OK
Practice Address - Zip Code:73651-1615
Practice Address - Country:US
Practice Address - Phone:580-726-3324
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK740363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKS15769Medicare UPIN
OKPA00740Medicare ID - Type Unspecified