Provider Demographics
NPI:1245475813
Name:PHILLIPS, ANTHONY DERRAL (RN, BSN)
Entity type:Individual
Prefix:
First Name:ANTHONY
Middle Name:DERRAL
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 CHINA GULCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97530-9744
Mailing Address - Country:US
Mailing Address - Phone:541-899-4911
Mailing Address - Fax:541-899-4911
Practice Address - Street 1:300 CHINA GULCH RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97530-9744
Practice Address - Country:US
Practice Address - Phone:541-899-4911
Practice Address - Fax:541-899-4911
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-10
Last Update Date:2008-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR099006484RN163WX0200X, 163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WX0200XNursing Service ProvidersRegistered NurseOncology