Healthcare Provider Details

I. General information

NPI: 1720119373
Provider Name (Legal Business Name): ALYSSA MARIE PHILLIPS PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5505 PEACHTREE DUNWOODY RD NE #270
ATLANTA GA
30342-1705
US

IV. Provider business mailing address

1230 DUNWOODY VILLAGE DR
ATLANTA GA
30338-2321
US

V. Phone/Fax

Practice location:
  • Phone: 404-303-7004
  • Fax: 404-303-7020
Mailing address:
  • Phone: 404-247-0144
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number003882
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: