Healthcare Provider Details

I. General information

NPI: 1568983922
Provider Name (Legal Business Name): BRYAN O PHILLIPS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2017
Last Update Date: 09/24/2025
Certification Date: 09/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2305 37TH AVE SW
MINOT ND
58701-7669
US

IV. Provider business mailing address

PO BOX 5010
MINOT ND
58702-5010
US

V. Phone/Fax

Practice location:
  • Phone: 701-857-5000
  • Fax:
Mailing address:
  • Phone: 701-857-5650
  • Fax: 701-857-5031

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPAC0698
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPAC0698
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: