Provider Demographics
NPI:1831185081
Name:PHILLIPS, MIKEL W (CRNA)
Entity type:Individual
Prefix:MR
First Name:MIKEL
Middle Name:W
Last Name:PHILLIPS
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 E LE FEVRE RD
Mailing Address - Street 2:
Mailing Address - City:STERLING
Mailing Address - State:IL
Mailing Address - Zip Code:61081-1278
Mailing Address - Country:US
Mailing Address - Phone:208-587-3501
Mailing Address - Fax:
Practice Address - Street 1:90 HOPE DR
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME A F B
Practice Address - State:ID
Practice Address - Zip Code:83648-1057
Practice Address - Country:US
Practice Address - Phone:208-828-7367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-23
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041-346550163W00000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILOTH000Medicare UPIN