Provider Demographics
NPI:1720491012
Name:PHILLIPS, SHAWN
Entity Type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54123 LISA DR
Mailing Address - Street 2:
Mailing Address - City:CALLAHAN
Mailing Address - State:FL
Mailing Address - Zip Code:32011-5989
Mailing Address - Country:US
Mailing Address - Phone:904-563-7550
Mailing Address - Fax:
Practice Address - Street 1:17080 SAFETY ST
Practice Address - Street 2:SUITE 109
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33908-7506
Practice Address - Country:US
Practice Address - Phone:888-499-5672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist