Healthcare Provider Details

I. General information

NPI: 1013531177
Provider Name (Legal Business Name): EAN PHILLIPS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2020
Last Update Date: 01/26/2023
Certification Date: 01/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 S DIXIE HWY STE 400
PINECREST FL
33156-6530
US

IV. Provider business mailing address

PO BOX 100905
ATLANTA GA
30384-2727
US

V. Phone/Fax

Practice location:
  • Phone: 786-467-5753
  • Fax:
Mailing address:
  • Phone: 786-594-6880
  • Fax: 352-273-7388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9113414
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: