Healthcare Provider Details

I. General information

NPI: 1235686866
Provider Name (Legal Business Name): PHILLIP ANTHONY MILLAN ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 04/02/2021
Certification Date: 03/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5425 MCWILLIAMS ROAD BLDG 5425
CAMP BULLIS TX
78257
US

IV. Provider business mailing address

11500 FENWAY SOUTH DR
FORT MYERS FL
33913-8671
US

V. Phone/Fax

Practice location:
  • Phone: 210-295-8337
  • Fax:
Mailing address:
  • Phone: 816-510-6837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL4509
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT7733
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: