Healthcare Provider Details

I. General information

NPI: 1063283463
Provider Name (Legal Business Name): SHANE T PHILLIPS MED, ATC/L, PES
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2024
Last Update Date: 01/15/2024
Certification Date: 01/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
ANCHORAGE AK
99506-3702
US

IV. Provider business mailing address

4610 REKA DR APT A19
ANCHORAGE AK
99508-3614
US

V. Phone/Fax

Practice location:
  • Phone: 907-580-2778
  • Fax:
Mailing address:
  • Phone: 303-883-6151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number123978
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: