Healthcare Provider Details

I. General information

NPI: 1275589491
Provider Name (Legal Business Name): JASON MICHAEL PHILLIS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 04/29/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2165 MEDICAL PARK DR
HICKORY NC
28602-8809
US

IV. Provider business mailing address

2165 MEDICAL PARK DR
HICKORY NC
28602-8809
US

V. Phone/Fax

Practice location:
  • Phone: 828-324-2800
  • Fax: 828-294-9160
Mailing address:
  • Phone: 828-324-2800
  • Fax: 828-294-9160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number102622
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: