Healthcare Provider Details

I. General information

NPI: 1932705951
Provider Name (Legal Business Name): MADELINE GRACE PHILLIPS PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/06/2020
Last Update Date: 01/27/2022
Certification Date: 01/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST
LEXINGTON KY
40536-7601
US

IV. Provider business mailing address

240 RICHLAND CHURCH RD
MORGANTOWN KY
42261-7601
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-9057
  • Fax: 859-323-9502
Mailing address:
  • Phone: 270-999-5703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberTC102
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberTC102
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA2892
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberTC102
License Number StateKY
# 5
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA2892
License Number StateKY
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA2892
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: