Healthcare Provider Details

I. General information

NPI: 1245475813
Provider Name (Legal Business Name): ANTHONY DERRAL PHILLIPS RN, BSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/10/2008
Last Update Date: 12/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 CHINA GULCH RD
JACKSONVILLE OR
97530-9744
US

IV. Provider business mailing address

300 CHINA GULCH RD
JACKSONVILLE OR
97530-9744
US

V. Phone/Fax

Practice location:
  • Phone: 541-899-4911
  • Fax: 541-899-4911
Mailing address:
  • Phone: 541-899-4911
  • Fax: 541-899-4911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WX0200X
TaxonomyOncology Registered Nurse
License Number099006484RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number099006484RN
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: