Provider Demographics
NPI:1912920232
Name:PHILLIPS, MARK T (PA)
Entity Type:Individual
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First Name:MARK
Middle Name:T
Last Name:PHILLIPS
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Gender:M
Credentials:PA
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Mailing Address - Street 1:20010 CENTURY BLOULEVARD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:20874-1106
Mailing Address - Country:US
Mailing Address - Phone:240-686-2300
Mailing Address - Fax:240-686-2303
Practice Address - Street 1:8700 SUDLEY ROAD
Practice Address - Street 2:PRINCE WILLIAM HOSPITAL
Practice Address - City:MANASSAS
Practice Address - State:VA
Practice Address - Zip Code:20110
Practice Address - Country:US
Practice Address - Phone:703-369-8337
Practice Address - Fax:703-369-8868
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-11-03
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Provider Licenses
StateLicense IDTaxonomies
VA0110001989363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q34921Medicare UPIN
VA006555E54Medicare ID - Type Unspecified