Healthcare Provider Details

I. General information

NPI: 1811969165
Provider Name (Legal Business Name): SHANNON E PHILLIPS JR. N.P.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 COTTAGE RD
CARTHAGE TX
75633-1466
US

IV. Provider business mailing address

P.O. BOX 76
CANTON TX
75103
US

V. Phone/Fax

Practice location:
  • Phone: 903-694-4824
  • Fax:
Mailing address:
  • Phone: 903-962-3419
  • Fax: 903-385-3340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number669011
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: