Provider Demographics
NPI:1669722393
Name:PHILLIPS, SCOTT ALAN (PA-C)
Entity type:Individual
Prefix:
First Name:SCOTT
Middle Name:ALAN
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 1:5777 NEW COPELAND RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75703-3905
Mailing Address - Country:US
Mailing Address - Phone:903-561-9255
Mailing Address - Fax:903-561-0034
Practice Address - Street 1:5777 NEW COPELAND RD
Practice Address - Street 2:SUITE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-3905
Practice Address - Country:US
Practice Address - Phone:903-561-9255
Practice Address - Fax:903-561-0034
Is Sole Proprietor?:No
Enumeration Date:2012-09-10
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA07893363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant