Provider Demographics
NPI:1982896254
Name:PHILLIS, GEORGE KENNIE (MPAS PAC)
Entity Type:Individual
Prefix:MR
First Name:GEORGE
Middle Name:KENNIE
Last Name:PHILLIS
Suffix:
Gender:M
Credentials:MPAS PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2605 N LEIGHTON CIR
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76309-4115
Mailing Address - Country:US
Mailing Address - Phone:940-691-9210
Mailing Address - Fax:940-691-1557
Practice Address - Street 1:1300 7TH STREET
Practice Address - Street 2:SUITE 110
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-2305
Practice Address - Country:US
Practice Address - Phone:940-761-7660
Practice Address - Fax:940-761-8806
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-10
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTXPA00550363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMP1180467OtherDEA NUMBER TX DPS