Provider Demographics
NPI:1134209398
Name:PHILLIPS, DOUGLAS ANTHONY (CRNA)
Entity type:Individual
Prefix:MR
First Name:DOUGLAS
Middle Name:ANTHONY
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:160 MELODY LN
Mailing Address - Street 2:
Mailing Address - City:DERIDDER
Mailing Address - State:LA
Mailing Address - Zip Code:70634-1902
Mailing Address - Country:US
Mailing Address - Phone:337-531-3344
Mailing Address - Fax:
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:BAYNE JONES ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3344
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN162763367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered