Provider Demographics
NPI:1912993510
Name:PHILLIPS, PEGGY S (NP)
Entity Type:Individual
Prefix:MRS
First Name:PEGGY
Middle Name:S
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:411 MORGANTOWN ST.
Mailing Address - Street 2:
Mailing Address - City:KINGWOOD
Mailing Address - State:WV
Mailing Address - Zip Code:26537
Mailing Address - Country:US
Mailing Address - Phone:304-329-0555
Mailing Address - Fax:304-329-0556
Practice Address - Street 1:411 MORGANTOWN ST.
Practice Address - Street 2:
Practice Address - City:KINGWOOD
Practice Address - State:WV
Practice Address - Zip Code:26537
Practice Address - Country:US
Practice Address - Phone:304-329-0555
Practice Address - Fax:304-329-0556
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV30549363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7103173000Medicaid
WV2019584Medicare PIN
WVP00083204Medicare PIN
WV2019583Medicare PIN
WV2019585Medicare PIN
WV2019582Medicare PIN
WV2019586Medicare PIN
S88021Medicare UPIN
WV2019581Medicare PIN