Provider Demographics
NPI:1396798401
Name:PHILLIPS, JASON VANN (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:VANN
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 BEAVER DAM RD
Mailing Address - Street 2:
Mailing Address - City:LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:27298-9146
Mailing Address - Country:US
Mailing Address - Phone:336-622-6913
Mailing Address - Fax:
Practice Address - Street 1:364 WHITE OAK ST
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5434
Practice Address - Country:US
Practice Address - Phone:336-629-8807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2023-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC102782363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2752282BMedicare PIN
S87185Medicare UPIN
NCS87185Medicare UPIN