Provider Demographics
NPI:1750768321
Name:ISON, PHILIP R (NP)
Entity type:Individual
Prefix:
First Name:PHILIP
Middle Name:R
Last Name:ISON
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3645 SANDBAR DR
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-1067
Mailing Address - Country:US
Mailing Address - Phone:313-732-1545
Mailing Address - Fax:
Practice Address - Street 1:3645 SANDBAR DR
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382-1067
Practice Address - Country:US
Practice Address - Phone:313-732-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-01
Last Update Date:2015-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704244865363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology