Healthcare Provider Details

I. General information

NPI: 1104904903
Provider Name (Legal Business Name): PHILLIP SHANNON FARRIS PA-C, MPAS.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1103 16TH AVE SE
DECATUR AL
35601-3595
US

IV. Provider business mailing address

2404 11TH ST SE
DECATUR AL
35601-4598
US

V. Phone/Fax

Practice location:
  • Phone: 256-350-0362
  • Fax:
Mailing address:
  • Phone: 256-353-2018
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-262
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: