Healthcare Provider Details

I. General information

NPI: 1649962515
Provider Name (Legal Business Name): PHILLIP THIRANOP PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2023
Last Update Date: 01/16/2025
Certification Date: 01/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 S MAIN ST
TRENTON FL
32693-3239
US

IV. Provider business mailing address

23476 NW 186TH AVE
HIGH SPRINGS FL
32643-0673
US

V. Phone/Fax

Practice location:
  • Phone: 352-463-2374
  • Fax: 352-463-2726
Mailing address:
  • Phone: 386-454-0698
  • Fax: 386-454-0690

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9117628
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: